
Qass. 
Book 



COPYRIGHT DEPOSIT 



OBSTETRICS 

NORMAL AND OPERATIVE 



BY 

GEORGE PEASLEE gHEARS, B.S., M.D. 

PROFESSOR OF OBSTETRICS AND ATTENDING OBSTETRICIAN AT THE NEW YORK POLYCLINIC MEDICAL 
SCHOOL AND hospital; FORMERLY INSTRUCTOR IN OBSTETRICS, CORNELL UNIVERSITY MEDICAL 
COLLEGE; ATTENDING OBSTETRICIAN AT THE NEW YORK CITY HOSPITAL; SENIOR 
ATTENDING OBSTETRICIAN AT THE MISERICORDIA HOSPITAL 

AND 

E. E. SHEARS, M.D. 



419 ILLUSTRATIONS 



SECOND REVISED EDITION 




PHILADELPHIA AND LONDON 
J. B. LIPPINCOTT COMPANY 



COPYRIGHT, I916, BY J. B. LIPPINCOTT COMPANY 
COPYRIGHT, I917, BY J. B. LIPPINCOTT COMPANY 



OCT 29't9)7 



Electrotyped and Printed by J. B. Lippincott Company 
The Washington Square Press, Philadelphia, U. S. A. 



CU477226 



/ M90 ^ 



PREFACE 

Ix the following pages I have endeavored to set down some of the 
results of a fairly extensive experience in the hospital, private, and 
consulting practice of obstetrics, and in the teaching of students, first 
of undergraduates at the Cornell University Medical College, and later of 
postgraduates at the Xew York Polyclinic. 

In spite of the fact that there are many excellent text-books in the 
field, I have ventured to think that there is room for another, based upon 
a different plan. ]\Iost obstetrics works, it seems to me, contain too much 
irrelevant matter and too little about the practice of obstetrics. This is 
because they are constructed upon a plan which, while it has the authority 
i tradition and custom, does not conserve the interests of either practitioner 
cr student. It is discouraging to both, for example, to find so large a 
space devoted to developmental anomalies and fetal monstrosities that 
little or none is left for the superlatively important subject of fetal mor- 
tality in labor. It is to the last degree exasperating to find a long biography 
of the Chamberlen family, and to search in vain for information as to 
the method of employment of that marvel of mechanism, the axis-traction 
forceps. 

Let us take another example. If in the course of a difficult version 
the operator finds it impossible to grasp a knee or foot, the difficulty may 
sometimes be obviated by the simple expedient of turning the patient upon 
her side. This is one of the most important facts in the whole range of 
clinical obstetrics, and yet, turning to some standard text-book, we find 
that it is either unknown or unnoticed, but observe at the same time that 
considerable space is devoted to the subject of the cause of menstruation. 

I have omitted the traditional section on embryology, which has become 
a science in itself and can be adequately treated only in a separate work. 
Of course, I would not minimize its importance. A knowledge of physi- 
ology is absolutely necessary to the intelligent practice of medicine, but 
no one would now think of taking up a large part of a work upon the 
practice of medicine with a preliminary treatise on physiology. The 
section on anatomy has been omitted for a similar reason. 

The theory of pure obstetrics, however, without a knowledee of which 



iv PREFACE 

the practice of obstetrics can never reach the dignity it deserves, has not 
been neglected. I have tried to give briefly and plainly the essentials, 
i.e., about as much as the student ought to know, or is likely to remember. 
Enough also to serve, if desired, as a groundwork for further study. 

This book contains many original photographs made especially for me 
at the Xew York City Hospital and elsewhere. These photographs seem 
to me to be unequalled, but perhaps I am a partial witness. For the privi- 
lege of reproducing, sometimes with slight modifications, certain illustra- 
tions, particularly Professor Fabre's collection of photographs showing the 
various forms of pelvic contraction, I am indebted to the publishing house 
of J. B. Bailliere et Fils, of Paris. Other illustrations have been borrowed, 
but always with due credit. I conceive it to be the duty of the author of a 
scientific work to give his readers the best illustrations he can get without 
reference to their source, provided, of course, due credit is always given. 
The purpose of such a work is not so much to extend the author's fame 
as a draughtsman, as to teach the reader what he wishes to know. Some 
original illustrations have no other merit than originality. 

I have not attempted to write a dictionary of bibliographical reference, 
and I have tried to omit those things which are of historic or academic 
interest only, and those things which every one knows, in order to have 
space for those essentials of the practice of obstetrics which many do not 
seem to know. 

Every text-book is to some extent a compilation, and it is well to 
acknowledge this at the outset. I trust, however, that this book will 
not be found wanting in the expression of individual opinion, and that 
where I have quoted much I have not failed to give due credit. 

In conclusion I would extend greeting and congratulation to all those 
who, whether as practitioners or as specialists, are engaged in the arduous 
and trying work of obstetric practice. In no department of medicine are 
more positive results obtained. In none is there greater alleviation of 
suffering or saving of human life. This beneficent work is its own reward. 



ACKNOWLEDGMENTS 

The following are taken from Fabre'sObstetrique, J. B.Bailliere et Fils, 
Publishers : Figures i, 2, 20, 22, 25, 26, 37, 38, 39, 40, 41, 42, 45, 48, 50, 88, 
98, 99, 100, loi, 102, 103, 104, 105, 106, 107, no, 113, 114, 121, 123, 124, 
129, 130, 132, 141, 142, 173, 176, 177, 178, 179, 185, 186, 187, 191, 212, 213, 

217, 218, 229, 230, 231, 234, 262, 263, 264, 266, 269, 271, 2^2, 280, 285, 286, 
288, 289, 290, 291, 292, 293, 294, 295, 296, 297, 298, 299, 300, 301, 302, 

303. 312, 314. 315. 316, 317, 318. 319, 340, 359. 362, 364, 367, 368, 369, 
374, 375. 376, 379, 380, 384, 387, 390, 391, 401, 411, 416. 

These have been redrawn : Figures 21, 23, 24, 84, 87, 115, 140, 143, 189, 
190, 214, 223, 224, 225, 226, 2^6, 237, 241, 242, 243, 284, 346, 347, 348, 351, 
352. 

From Bumm's Grundriss zum Studium der Geburtshilfe, J. F. Berg- 
mann, PubHsher: Figures 3, 9, 17, 18, 31, 52, 53, 70, 71, 72, 75, y6, 82, 83, 
85, 86, 91, 92, 94, 95, 96, 97, 116, 133, 134, 149, 154, 155, 158, 159, 181, 194, 
199, 200, 201, 204, 239, 240, 274, 278, 281, 370, 373, 377, 382, 395, 418. 

These have been redrawn: Figures 4, 5, 15, 16, 136, 238, 287, 365, 366. 

From Garrigues's Obstetrics : Figures 6, 7, 8, 32, 33, 73, yy, 78, 79, 89, 
90, 144, 145, 146, 150, 151, 152, 153, 156, 171, 174, 175, 193, 202, 203, 
205, 206, 207, 219, 220, 221, 222, 228, 235, 273, 2^6, 343, 392, 393, 398. 

From Jeannin and Gueniot's Therapeutique Obstetricale et Gynecolog- 
ique, J. B. BailHere et Fils: Figures 147, 148, 172, 188, 232, 233, 247, 259, 
270, 320, 333, 334, 335, 336, 337, 338, 360, 361, 363, 371, 372, 383, 389, 394, 
396, 397, 400, 402, 403, 406, 407, 408, 409, 410, 412, 413, 414, 415, 419. 

From Cooke's A Nurse's Hand Book of Obstetrics, Seventh Edition: 
Figures 109, 135, 137, 138, 139, 244, 245, 248, 250, 251, 253, 254, 255, 256, 
257, 282, 283, 324, 326, 2,27, 417. 



CONTENTS 

PART I 

PAGE 

CHAPTER I.— PREGNANCY, LABOR AND THE PUERPERIUM 

Changes in the Maternal Organism Resulting from Pregnancy i 

Local Changes i 

The Uterine Musculature 5 

The Growth of the Uterus 9 

Shape and Position of Uterus 9 

Uterine Inclination and Torsion 10 

Relations of the Uterus 12 

Cervix and Adnexa 12 

Vagina, Vulva, Perineum and Pelvic Floor 16 

Pelvic Joints , 16 

Abdomin-\l Walls 17 

Gener.\l Changes 18 

Heart and Circulatory Apparatus 18 

Blood 19 

Respiratory Apparatus 20 

Alimentary Canal 20 

Glandular System 21 

Urine and Urinary Tract 22 

Skin 23 

Mind and Nervous System 24 

Bones 24 

Nutrition and Metabolism 25 

CHAPTER n.— THE DIAGNOSIS AND CLINICAL PHENOMENA OF 

PREGNANCY 

Importance of the Subject 27 

Relative Value of Symptoms 28 

Symptoms of First Half of Pregnancy 28 

Importance of Early Bimanual Examination 32 

Results of Inspection, Palpation and Vaginal Examination 32 

Changes in the Uterus 32 

Changes in the Breasts 42 

Symptoms of the Second Half of Pregnancy 43 

Positive Signs 43 

Duration of Pregnancy 44 

To Determine Whether the Foetus is Alive 46 

The Diagnosis of Multiparity 47 

Serodiagnosis of Pregnancy 48 

Pseudocyesis 50 

CHAPTER III.— THE MANAGEMENT OF PREGNANCY 

General Examination 55 

Hygiene 55 

Care of the Nipples 59 

Examination of the Urine 60 

Mental Hygiene 60 

Prophylaxis 61 

vii 



vlii CONTENTS 

CHAPTER IV.— THE ANTEPARTUM EXAMINATION 

Its Importance 63 

External 64 

Position of Patient 64 

Inspection 64 

Palpation 64 

Auscultation 79 

Fetal Heart 79 

Fetal Souffle 82 

Uterine Souffle 82 

Internal Examination 82 

Condition of Soft Parts 83 

Internal Pelvimetry 83 

CHAPTER v.— THE FGETUS IN UTERO 

Attitude 84 

Position 84 

Presentation 87 

Classification 87 

Nomenclature 87 

CHAPTER VI.— THE PHYSIOLOGY AND MECHANISM OF LABOR 

Anatomy of the Pelvis 94 

Differences Between Male and Female Pelves 99 

The Pelvis of Infancy and Childhood 100 

The Fet.\l Head 100 

The Physiology and Cause of Labor 107 

Innervation of the Uterus 109 

Dilatation of the Cervix no 

The " Bag of Waters " 112 

Placental Expulsion 116 

Mechanism in Anterior Positions of the Occiput 117 

CHAPTER VIL— THE DIAGNOSIS AND CLINICAL PHENOMENA OF 

LABOR 

Premonitory Symptoms 128 

How to Know When Labor Has Begun 128 

The Contractions of Labor 130 

Why They are Accompanied by Pain 133 

Atypical Labor 136 

CHAPTER VIIL— THE MANAGEMENT OF LABOR 

Preparation 138 

Physician's Outfit 139 

At the Home of the Patient 141 

The Patient Herself 142 

The Prevention of Infection 143 

Technic of Vaginal Examination i^i 

Conduct of the First Stage 154 

General Hygiene i^^ 

Anesthesia 156 

"Twilight Sleep" 1^7 

Conduct of the Second Stage 162 

Care of the Perineum 163 

Delivery of the Shoulders 168 

Physical and Moral Support 168 

Attention to the Fcetus 170 

Ligation and Care of the Cord lyi 

Prophylaxis of Gonorrhgeal Ophthalmia iy2 

Conduct of the Third Stage ][ 172 

Prevention of Hemorrhage 174 

Complete Expulsion of Placenta and Membranes 174 



CONTENTS ix 

CHAPTER IX.— THE PHYSIOLOGY AND CLINICAL HISTORY OF 
THE PUERPERIUM 

Involutiox of the L'terus 182 

Characteristics of the Postpartum Uterus 183 

Involution of Cervix and Vagina 187 

Clinical Course of the Puerferium 189 

CHAPTER X.— THE MANAGEMENT OF THE PUERPERIUM 

Rest and Sleep 194 

Prevention of Infection 195 

After-Pains 197 

Catheter and Vaginal Douche 199 

Temperature and Plxse 201 

Breasts and Nipples 203 

Care of the New-born Child 206 

Posture of Patient in Bed 208 

When May She Leave Her Bed 209 

CHAPTER XL— MULTIPLE PREGNANCY AND LABOR 

Definition, Frequency, Etiology 212 

Development 212 

Diagnosis 215 

Clinical History 217 

Treatment in Pregnancy and Labor 218 



PART II 

PATHOLOGY OF PREGNANCY AND LABOR 
CHAPTER XIL— LOCAL DISORDERS OF THE MOTHER 

Inflammations of the Genital Tract 223 

Uterine and Other Tumors 229 

Malpositions of the Uterus 240 

Structural Anomalies of Uterus 246 

Atresia 250 

CHAPTER XIIL— GENERAL DISORDERS OF THE MOTHER 

Toxaemia of Pregnancy 253 

Eclampsia 260 

Vomiting of Pregnancy 273 

Acute Yellow Atrophy of the Liver 280 

Chorea Gravidarum 281 

CHAPTER XIV.— INTERCURRENT AFFECTIONS 

Chronic Infectious Diseases , 283 

Syphilis 283 

Tuberculosis 289 

Acute Infectious Diseases 291 

Circulatory System 295 

Respiratory System 298 

Urinary Tract 299 

Gastro-intestinal Disturbances 304 

Nervous System 305 

Cutaneous 307 

Surgical Operations in Pregnancy 307 



X CONTEXTS 

CHAPTER XV.— THE PRE^IATURE INTERRUPTION OF PREGNANCY 
Clinical History and Management of Abortion and Premature Labor. . . 308 

CHAPTER XVI.— EXTRA-UTERINE PREGNANCY 

Clinical History and Diagnosis 324 

Treatment 33^ 

CHAPTER XVII.— ANO.MALIES OF THE FCETUS AND ITS 
APPENDAGES 

Hydrocephalus 334 

Anenceph.\lus 337 

Abnormalities of the Placenta • 338 

Anom.\lies of the Cord 344 

Diseases of the Chorion 346 

Diseases of the Amnion 350 

CHAPTER XVIII.— ANO^IALIES OF THE EXPELLENT FORCES 

Uterine Inertia 354 

Rigidity of the Cervix 356 

Excessive Uterine Retraction 365 

Tetanic Contraction of Uterus 365 

Precipitate Labor 366 

CHAPTER XIX.— MALPOSITIONS AND MALPRESENTATIONS OF 

THE FCETUS 

Posterior Positions of the Occiput 368 

Transverse Presentations 375 

Breech, Face and Brow Presentations 385 

CHAPTER XX.— FETAL MORTALITY IN LABOR 

Causes, Diagnosis, Prevention and Treatment of Fetal Asphyxia 404 

Prolapse of the Cord. 426 



CHAPTER XXL— LACERATIONS OF THE GENITAL TRACT 
DURING LABOR 
Repair of Perineal Lacerations 



431 



HiEMATOMA 444 

Tears of Vagina and Cervix 4^.5 

Rupture of Uterus 446 

Inversion of Uterus 4^^ 



CHAPTER XXII.— THE PUERPERAL HE^IORRHAGES 
Postpartum 



459 



Cervical 47 1 

Late ^ 473 

Placenta Pr.evia 474 

Accidental 483 

CHAPTER XXIIL— CONTRACTED PELVIS 

Etiology 488 

Classification 4^0 

Pelvimetry ^lo 

Clinical Course of Labor ^25 

Choice Between Forceps Operation and Version 530 



CONTENTS xi 

PART III 

OBSTETRIC SURGERY 

CHAPTER XXIV.— GENERAL TECH NIC OF OBSTETRIC OPERATIONS 

General Remarks 539 

The Operating Table 541 

An.esthesl\ 543 

Asepsis and Antisepsis 547 

Final Examination 548 

Attention to the Fcetus 548 



CHAPTER XXV.— PROCEDURES DESIGNED TO OVERCOME THE 
RESISTANCE OF THE CERVIX 

Artificial Dilatation 

The Vaginal Cesarean Section 



550 
559 



Cervical Incisions 566 

CHAPTER XXVI.— THE INDUCTION OF ABORTION AND OF PREMA- 
TURE LABOR 

Indications 567 

Technic of the Induction of Abortion 568 

During the First Three Months 568 

During the Second Three Months 570 

Methods for the Induction of Premature Labor 570 

CHAPTER XXVII.— THE FORCEPS 

Construction 574 

Varieties 576 

Choice of Instrument 577 

Choice Between Forceps and Version 580 

Technic of the Low, Median and High Operations 586 

The Axis-traction Forceps 595 

In Posterior Positions of the Occiput 600 

In Breech Presentation 602 

In Face Presentation 603 

Forceps to the After-coming Head 605 

CHAPTER XXVIII.— VERSION 

Internal Podalic Version 609 

Preliminary Dilatation of the Cervix 612 

Difficulties and Complications 619 

Breech Extraction 620 

Delivery of the Extended Arms 62 1 

Delivery of the After-coming Head 624 

The Cervix as an Obstacle to Delivery 629 

External Version 630 

Bipolar Method 631 

Pelvic Version 635 

CHAPTER XXIX.— THE CESAREAN SECTION 

History and Recent Improvements in Technic 636 

Indications 636 

Prognosis 637 

Time for Operation 637 

Technic of Different Methods 639 

After-treatment 645 

The Porro Operation 640 

Extraperitoneal Cesarean Section 649 



xli CONTENTS 

CHAPTER XXX.— SYMPHYSIOTOMY AND PUBIOTOMY 

Symphysiotomy ^53 

Technic 653 

After-treatment ^56 

pubiotomy ^57 

Techxic ^57 

After-treatment 060 

Indications ^^^ 

Prognosis ^^3 

CHAPTER XXXI.— EMBRYOTOMY 

Indications 664 

Craniotomy 665 

Cranioclasis • • • • 670 

Cephalotripsy 671 

Basiotripsy 671 

Decapitation 676 

Evisceration 680 

Cleidotomy 682 



PART l\' 

PATHOLOGY OF THE PUERPERIUM 

CHAPTER XXXIL— PUERPERAL INFECTION 

History 683 

Frequency 683 

Classification 684 

Sapr^mia 685 

Septicemia 686 

Diagnosis 699 

Treatment 703 

CHAPTER XXXIIL— AFFECTIONS OF THE BREASTS AND NIPPLES 

Engorgement of the Breasts 712 

Inspissation of Milk 714 

Erosions of the Nipple 714 

Fissures of the Nipple 717 

Puerperal Mastitis 717 

Anomalies of the Milk Secretion 722 

Supernumerary Breasts 724 

Hypertrophy of the Breasts 724 

CHAPTER XXXIV.— OTHER COMPLICATIONS OF THE PUERPERIUM 

Subinvolution 725 

Superinvolution 726 

Displacements of the Uterus 727 

Intercurrent Affections 728 

The Puerperal Psychoses 729 

Postpartum Paralysis 731 

Duchenne's Paralysis 733 

Delayed Chloroform Poisoning 733 

Puerperal Myalgia • 734 



ILLUSTRATIONS 

Fig. page 

1 . Non-pregnant Uterus. 2 

2. Uterus at Time of Delivery 3 

3. Xon-striated jNIuscle of the Uterus 4 

4. Case of Brow Presentation with Threatened Rupture of the Uterus 5 

5. Overstretching Due to Obhque Position 5 

6. The ^Musculature of the Pregnant Uterus, Dissected and Seen from the Side . . 6 

7. The Musculature of the Pregnant Uterus, Front View 7 

8. The Submucous Muscular Layer of the Pregnant Uterus 8 

9. Vascular System of the Uterus. (In color) 9 

10. Pear-shaped Uterus 10 

1 1 . Spherical Uterus 10 

12. Ovoid Uterus 1 1 

13. Uterus at Successive Months 11 

14. Relation of the Colon to the Pregnant Uterus 13 

15. Pregnant Uterus at the Third Month, Posterior Aspect 14 

16. Ovoid Uterus of Advanced Pregnancy 15 

17. Seventh Month. Head High, Vaginal Vault Preserved . 16 

18. Shows Obliteration of Anterior Lip of Cervix, Head Having Entered the Pelvis 17 

19. Abdominal Striae 25 

20. Sensation Imparted to the Palpating Finger by (a) the Non-pregnant Uterus, 

(b) the Pregnant Uterus 31 

21. Hegar's Sign 32 

22. Hegar's Sign. Negative, Uterine Hypertrophy Being Due to a Fibroma 33 

23. McDonald's Sign 34 

24. Ladinski's Sign 35 

25. Height of Fundus at Different Periods of Pregnancy 40 

26. Measuring Height of Fundus at Term 41 

27. 28. Virgin and Pregnant Blonde. (In color) 42 

29, 30. Virgin and Pregnant Brunette. (In color) 42 

31. Ahlfeld's Method of Determining the Period of Development ■ 46 

32. Hysterical Tympanites 50 

33. The Same Patient when Anaesthetized 51 

34. Outlining the Fundus 65 

35. Usual Method of Palpating the Abdomen 66 

36. A Better Method 66 

37. Vertex Presentation; Palpation of the Small Parts 67 

38. Vertex Presentation; Palpation of the Back 68 

39. Palpating the Shoulder in Vertex Presentation 69 

40. Measuring Height of the Anterior Shoulder above the Pelvic Brim 70 

41. Measuring the Distance of the Anterior Shoulder from the Median Line in 

R. O. P. Position . 71 

42. Measuring the Distance of the Anterior Shoulder from the Median Line in 

L. O. T. Position 71 

43. Locating the Shoulder 72 

44. Locating the Shoulder, Same Patient, Three Weeks Later 73 

45. Bimanual Palpation 74 

46. Palpating the Fetal Head above the Brim. Bimanual Method 75 

47. Palpating the Head by the Unimanual Method 76 

48. Unimanual Palpation; Head Movable 77 

49. The Same Case as Fig. 47, Three Weeks Later 78 

50. Monaural Stethoscope 80 

51. Listening to the Fetal Heart Without Touching the Stethoscope 81 

52. Normal Attitude of Foetus in Utero 85 

53. Mechanism of Uterine Contractions in Transverse Position of Foetus 86 

xiii 



xlv ILLUSTRATIONS 

54» 55» 56, 57. Positions of Occiput in Order of Frequency 88 

58, 59, 60, 61. Positions of Face Presentation 89 

62, 63, 64, 65. Positions of Breech Presentation 90 

65, 67, 68, 69. Positions of Shoulder Presentation 91 

70. Normal Female Pelvis, Viewed from Above 95 

7 1 . Normal Pelvis, Viewed from Below 96 

72. Sagittal Section of Normal Pelvis 97 

73. True Pelvis, Life Size 98 

74. Diagram Showing Pelvic Axis 99 

75. Change in Length of Conjugate Diameter upon Maximum Stretchmg of Pelvis loi 

76. Walcher's Position 102 

77. Fetal Head, Side View 103 

78. Fetal Head, from Above 104 

79. Fetal Head, from Behind 105 

80-81. Diagram Showing Effect of Flexion, Conversion of Occipitofrontal into 

Suboccipito Bregmatic Diameter 106 

82. Genital Nerv^ous System in the Female ' 108 

83. A. Arrangement of Fibres in Gravid Uterus; B. Rearrangement of the Same 

in Retracted Uterus no 

84. Showing Changes in Uterus at the End of Period of Dilatation in 

85. Cervix of a Primipara at Beginning of Labor 112 

86. Primipara. Period of Dilatation. Upper Half of Cervix Unfolded 113 

87. Cylindrical Bag of Waters 114 

88. The Amniotic Sac Projects into the Vagina in a Long Narrow Pouch 115 

89. Expulsion of the Placenta According to Baudelocque 116 

90. Expulsion of the Placenta According to Duncan 116 

91. Primipara at Beginning of Labor. Head Well Flexed 118 

92. ]Multipara. Beginning of Labor. Moderate Flexion, Still Movable 119 

93. Shows Why the Head Does Not Engage in the Transverse Diameter of the 

Superior Strait 120 

94. Synclitic or Parallel Entrance of Head into Pelvic Brim 121 

95. Posterior Asynclitism 122 

96. Anterior Asynclitism 123 

97. Pelvic Floor, Viewed from Above 124 

98. Position, L. O. A. Degree of Rotation in Anterior Cases, One-eighth of a Circle 125 

99. Position, R. O. A. Degree of Rotation, One-eighth of a Circle 125 

100. Position, R. O. P. Degree of Rotation in Posterior Cases About Three-eighths 

of a Circle 126 

loi. Position, L. O. P. Degree of Rotation about Three-eighths of a Circle 126 

102. Cervix of Multipara Before Beginning of Labor. Dilatation "Without Efface- 

ment 129 

103. Cervix of Primipara at Beginning of Labor 129 

104. Cervix of Primipara. Beginning Effacement 129 

105. Cervix of Primipara. Effacement Complete. Beginning Dilatation 129 

106. Method of Internal Hysterography 132 

107. Combined ^Method 133 

108. Composite Picture Showing Abdominal Outline Before and During a Con- 

traction 135 

109. Delivery Bag w^ith Physician's Outfit 139 

no. A Drop of Tincture of Iodine AppHed to the Subungual Region Extends 

Readily to the Parts so Difficult to Disinfect 144 

111. Top, Hand with Usual Variety of Glove; Bottom, Long Glove 145 

112. Patient Prepared for Pelvic Examination 147 

113. Digital Examination in Vertex Presentation, L. O. P 152 

114. Vertex Presentation, R. O. A 153 

115. Diagram Showing Position of the Small Fontanelle in Relation to the Superior 

Strait 15^ 

1 16. Head Resting on Left Ileum 163 

117. Preserving the Perineum 164 

118. Another Case. Preservdng the Perineum 165 

119. The Same Case. Farther Advanced 166 



ILLUSTRATIONS xv 

120. The Same Case Again. Emergence of the Forehead and Face 167 

121. Passing a Loop of the Cord over the Fetal Head 168 

122. The Same Case as in Fig. 119, Continued. Dehvery of the Anterior Shoulder 169 

123. Expulsion of Placenta Aided by Pressure over Fundus After Complete Sep- 

aration 175 

124. Placenta and ^Membranes Fall into the Hand 176 

125. Expressing the Placenta by the Method of Crede 177 

126. Twisting the Membrane into the Form of a Rope to Prevent Tearing 178 

127. Inspecting the Placenta 179 

128. Frozen Section Just After Completion of Third Stage of Labor, Showing 

Collapse of Lower Uterine Segment and Cer\'ix 183 

129. Position of Fundus of Uterus Twenty-four Hours After Labor 184 

130. Position of Fundus of Uterus Forty-eight Hours After Labor 185 

131. Sagittal Section of the Pelvic Organs of a Puerpera on the Second Day After 

Delivery 1 86 

132. Position of Fundus of Uterus Three Days After Labor 187 

133. Puerperal Uterus of the Fifth Day 188 

134. Puerperal Uterus of the Twelfth Day 189 

135. "Watching the Fundus After Delivery 195 

136. Elastic Bandage 20 Centimetres Wide and 6 Metres Long 197 

137. Dr. Cooke's Breast Binder 202 

138. Pattern of Dr. Cooke's Breast Binder 203 

139. Nipple Shield, Best Kind 205 

140. Schematic Representation of Different Varieties of Multiple Pregnancy 213 

141. Twins with Communicating Circulations 214 

142. Hearts of Twins Shown in Fig. 141, Natural Size 215 

143. Height of Fundus and Circumference at the Umbilicus Notably Increased in 

Twin Pregnancy 216 

144. Twins, One in Vertex, the Other in Breech Presentation 219 

145. Locked Twins, Both in Head Presentation 220 

146. Locked Twins, First Child Partly Bom in Breech Presentation, the Second 

Lodged with the Face Under the Chin of the First 220 

147. First Child Presents by the Breech. Perforation of After-coming Head 221 

148. Twins. Both Heads Presenting. Perforation of First Child 222 

149. Diagram Showing the Different Kinds of Liquor Amnii 224 

150. Interstitial Inflammation of the Decidua 225 

151. Endometritis Tuberosa and Polyposa 225 

152. Retrocer\'ical Fibromyoma Filling the Pelvis. Caesarean Section at Term. . . 230 

Fibrous Polypus of Cervix Occupying the Vagina 231 

Large Myoma Obstructing Pelvic Inlet 235 

Same Uterus as Fig. 154 During Period of Dilatation 236 

Head Arrested at Brim by an Ovarian Cyst 237 

Retroflexion of the Gravid Uterus 239 

Retrofiexed Uterus, Partially Replaced at End of Pregnancy 241 

Pushing up the Incarcerated Uterus, with Aid of Knee-chest Position 242 

Dystocia Following Ventro Suspension 244 

Prolapsed Pregnant Litems 245 

Pregnant Uterus in Sac of Inguinal Hernia 246 

Diastasis of Recti Muscles with Hernia of Pregnant Uterus 247 

Uterus Unicornis 248 

165. Uterus Pseudo-Didelphys 248 

166. Uterus Bicornis Duplex 248 

167. Uterus Bicornis vSeptus 248 

168. Uterus Bicornis Subseptus 248 

169. Uterus Bicornis Unicollis 248 

170. Uterus Bicornis Unicollis with Rudimentary Horn 248 

171. Uterus Duplex Separatus, or Uterus Didelphys 249 

172. Episiotomy 251 

173. Microphotograph of Syphilitic Artery 285 

174. Villi fn^m the Line of Demarcation Between Healthy and Diseased Placental 

Tissue 286 

175- Syphilitic Villus of the Chorion 286 



xvi ILLUSTRATIONS 

176. ;Macerated Foetus : • 287 

177. Case of Albuminuria. White Infarcts of Placenta Which has been Cut m 

Sections and Placed so as to Show the Fetal Aspect 300 

178. Decidual Abortion 311 

179. Placental Abortion 3ii 

180. Showing Manner of Bringing Uterus in Line with Vagina 316 

181. Curette, Natural Size 3^7 

182. Perforation of Retrofiexed Uterus 318 

183. Thrombus at Placental Site, Simulating Polypus 320 

184. Broad Ligament Pregnancy 324 

185. Anterior Haematocele. (In color) 326 

186. Posterior Haematocele. (In color) 327 

187. Hemorrhage into the Peritoneal Cavity. (In color) 328 

188. Tubal Pregnancy. Clamp Applied to Broad Ligament at the Uterus 332 

189. Signs of Hydrocephalus During Pregnancy. Fundus High 334 

190. Palpating the Hydrocephalic Head 335 

191. H3-drocephalicAiter-comingHead. Extracted by Means of Crotchet in IMouth 336 

192. Anencephalus 337 

193. Helen and Judith, Ischiopagse 338 

194. Placenta with Three Succenturiate Placentce 339 

195. Placenta Tripartita 340 

196. Placenta Septuplex 341 

197. Placenta Bipartita 341 

198. Placenta Duplex with Two Succenturiate Lobules 342 

199. Normal Central Insertion of the Umbilical Cord 343 

200. Marginal Insertion of the Umbilical Cord 343 

201. Velamentous Insertion 344 

202. C3'stic Degeneration of Villi of the Chorion 345 

203. Uterus Containing a Vesicular JNIole 346 

204. Partial Myxoma of the Placenta 346 

205. Deciduoma Malignum 347 

206. Chorio-epithelioma Malignum 348 

207. Sagittal Section Through the Pelvic Organs of a Patient with Chorio-epitheli- 

oma Malignum 349 

208. Kristeller's Expression of Foetus 364 

209. Head Presenting at Brim; Occiput Behind; Biparietal Diameter Lying Behind 

Oblique Diameter of Pelvis 370 

210. Head Presenting at Brim; Occiput in Front; Biparietal Diameter Lying in 

Oblique Diameter of Pelvis 370 

211. Showing Mode of Delivery When Occiput Does Not Rotate Forward 370 

212. Delivery in the Occipito-sacral Position 374 

213. Delivery in Posterior Position, External Restitution 374 

214. External Appearance in Transverse Position 375 

215. Palpation in Longitudinal Position 376 

216. Palpation in Transverse Position 377 

217. Shoulder Presentation. Palpating Hand Grasps the Head 378 

218. BaUottement in Case of Shoulder Presentation 379 

219. Spontaneous Evolution, First Stage 381 

220. Spontaneous Evolution, Second Stage 381 

221. Spontaneous Evolution, Third Stage 381 

222. Spontaneous Evolution, Fourth Stage 381 

223. Version for Transverse Position. Back Anterior 382 

224. Version for Transverse Position. Back Anterior 383 

225. Version for Transverse Position. Back Posterior 384 

226. Version for Transverse Position. Back Posterior 385 

227. Diagram Showing How ObHquity of the Uterus Produces Footling Pres- 

entation 386 

228. Lateral Flexion of Fetal Body in Breech Presentation 387 

229. Palpation of the Shoulder in Breech Presentation 388 

230. Palpation of the Head in Breech Presentation 389 

231. BaUottement in Case of Breech Presentation 390 

232. Breech Presentation with Legs Extended. Ready to Flex the Knee, First Step 392 



ILLUSTRATIONS xvii 

233. Breech Presentation with Legs Extended. Bringing Down a Foot, Second 

Step 393 

234. Releasing the Anterior Hip 394 

235. Face Presentation Due to Latero-version of the Uterus. . 395 

236. Anterior Rotation of Chin in R. M. P. Position. Three-eighths of a Circle.. . 396 

237. Anterior Rotation of Chin in L. M. A. Position. One-eighth of a Circle 396 

238. Face Presentation 397 

239. ^Mechanism in Face Presentation, Chin Anterior 398 

240. Face Presentation. Chin Has Rotated Posteriorly. Arrest of Labor 399 

241. Face Presentation, the Head INIarkedly Extended 400 

242. Brow Presentation, the Head Moderately Extended 401 

243. Deformation of the Head in Brow Presentation 402 

244. T.^eatment of Case of Asphyxia Livida 411 

245. Same with Rhytlimical Compression of Chest 412 

246. Tongue Traction. An Invaluable Resource in Asphyxia Neonatorum 413 

247. Introduction of Lars'ngeal Tube 414 

248. Alethod of Using the Lars^ngeal Tube 415 

249. Holden's Oxygen Insufflation 416 

250. Harvie Dew's Method of Artificial Respiration; Inspiration 417 

251. Harvie Dew's Method of Artificial Respiration; Expiration 418 

252. Prochownik's IMethod of Resuscitation 419 

253. Sylvester's Method; Inspiration 420 

254. Sylvester's Method; Expiration • 421 

255. Sylvester's IMethod with Tongue Traction 422 

256. Schultze's Alethod; Inspiration 423 

257. Schultze's Method; Expiration 424 

258. Improvised Repositor 429 

259. Showing Emmett Needle and Use of the Volsella 433 

260. Taking a Suture in a Tear of the First Degree 435 

261. Same Case. Sutures of Silkworm Gut 436 

262. Introduction of Sutures in a Tear of the First Degree 437 

263. Tear of the First Degree. Sutures in Place 438 

264. Tear of the First Degree. Sutures Tied 438 

265. Repair of Unilateral Second Degree Tear of Pelvic Floor 439 

266. Tear Involving the Sphincter Ani. Sutures in Place 440 

267. Repair of the Recto-vaginal Septum. Correct Method 442 

268. Repair of the Recto-vaginal Septum. Incorrect Method 442 

269. Tears in the Region of the Vestibule 443 

270. Immediate Repair of the Cervix 446 

271. Character of the Lower Uterine Segment in a Primipara at the Eighth Month 447 

272. Character of the Lower Uterine Segment in a Primipara at Term 447 

273. Rupture of the Anterior Wall of the Cervix Uteri 448 

274. Pressure Against Cervix Posteriorly, Anterior Vaginal Wall and Neck of 

Bladder, in Case of Contracted Pelvis 449 

275. Inversion of Uterus 456 

276. Urethra Dilated for Introduction of Finger into the Bladder 457 

277. Intra-uterine Douche-tube, Natural Size 464 

278. Uterus Tamponed by the Manual Method 465 

279. Instrumental Compression of the Abdominal Aorta 466 

280. The Closed Fist as an Emergency Tampon 467 

281. Bimanual Compression of Atonic Uterus 468 

282. Saline Infusion 469 

283. Hypodermoclysis 470 

284. Normal and Abnormal Placental Sites 475 

285. The de Ribes Bag in Placenta Prasvia 481 

286. Diagram Representing a Total Separation of Normally Implanted Placenta 483 

287. I. Normal; 2. Generally Contracted; 3. Flat; 4. Generally Contracted Flat; 

5. Transversely Contracted; 6. Obliquely Contracted; 7. Osteomalacic. ... 491 

288. Myxcedema. Well-marked Goitre. Flat Pelvis 493 

289. Rhachitic Pelvis, Median Section. Contraction at the Brim Only 494 

290. Rhachitic. Marked Deformity of Lower Limbs 495 



xvill ILLUSTRATIONS 

291. Rhachitis. Pelvic Contraction 495 

292. Symmetrical but Generally Contracted Pelvis 496 

293. Rhachitis; Generally Contracted Pelvis with False Sacral Promontory, Lower 

Limbs Little Affected 496 

294. True Dwarf Unusually Small 497 

295. Dwarf with Thyroid Atrophy. Generally Contracted Pelvis 497 - 

296. Chondrodystrophic Dwarf 498 

297. Rliachitis. Right Genu Valgum. Flat and Generally Contracted Pelvis. . . . 499 

298. Rhachitis. Double Genu Valgimi. Pelvis Flat and Generally Contracted. . . 499 

299. Kyphosis. Contraction of Pelvic Outlet. . 501 

300. Dorsolumbar Kyphosis. Outlet Contracrion 501 

301. Contraction at the Outlet. Coxalgic Pelvis 503 

302. Transverse Contraction at the Brim 504 

303. Fracture of the Pelvis. Narrowing of the Excavation 507 

304. The Raute of MichaeHs 510 

305. Measuring the Distance Between the Iliac Spines 511 

306. Measuring the Distance Between the Trochanters 512 

307. Measuring the External Conjugate 515 

308. Taking the Anteroposterior Diameter of the Pelvic Outlet 515 

309. Taking the Transverse Diameter of the Outlet 516 

310. Taking the Diagonal Conjugate. Pelvis Flat. Elbow Not Depressed 517 

311. Further Illustration of the Method of Taking the Diagonal Conjugate 518 

312. Distance Measured by Assistant 519 

313. Taking the Diagonal Conjugate, Continued. Distance Measured by Assistant 520 

314. Mechanism in Flat Pelvis. Position L. O. T 523 

315. Mechanism in Generally Contracted Pelvis. Position L. O. A . 523 

316. Mechanism in Flat and Generally Contracted Pelvis; First Method. Position 

L.O.T 523 

317. Mechanism in Flat and Generally Contracted Pelvis; Second Method. Posi- 

tion L. O. T 523 

318. Transverse Contraction at the Outlet 524 

319. Irregular Contraction at the Outlet 524 

320. Oblique Application of Forceps Above the Brim, Head in L. O. T. Position, . . 533 

321. Walcher Posture. Black Line Denotes Conjugate Diameter of the Brim. . . . 535 

322. The Anterior and Posterior Sagittal Diameters at the Outlet 537 

323. Improvised Operating Table in Private House. The Imitation Kelly Pad is 

Made of White Oilcloth 542 

324. Robb's Legholder 543 

325. Patient upon the Table. A Twisted Sheet Keeps the Thighs Flexed upon the 

Abdomen 544 

326. Doctor's Operating Gown, Cap, Mask and Gloves 545 

327. Nurse's Operating Gown, Cap, Mask and Gloves 545 

328. Bimanual Dilatation of Cervix 551 

329. Barnes Bags 554 

330. Champetier de Ribes Bag Folded on Itself 554 

331. Introduction of the de Ribes Bag. An Assistant is Holding the Cervix with 

Two Tenacula 555 

332. The Bag Being in Place the Operator Fills it with Sterile Water by Means of 

the Syringe 557 

333. Vaginal Hysterotomy. Separating the Cervical Mucous Membrane 560 

334. Vaginal Hysterotomy. Stripping the Mucous Membrane from the Cervix . . . 560 

335. Vaginal Hysterotomy. Longitudinal Median Incision 561 

336. Vaginal Hysterotomy. Anterior Incision Having Been Made, the Operator 

is About to Make a Posterior One 562 

337. Vaginal Hysterotomy. Stripping the Mucous Membrane Posteriorly. Pre- 

liminary Incision 562 

338. Vaginal Hysterotomy. Suture of Anterior Incision 564 

339. Method of Using the Placental Forceps 569 

340. Introduction of the Bougie 571 

341. Hodge, Simpson and Davis Forceps 575 

342. Tucker-McLane Forceps 576 



ILLUSTRATIONS xlx 



343. The Xaegele Forceps 577 

345. Tamier Axis- traction Forceps.. . ■■ - ■ ■^■. ■„■.■■-■-■■■■--■-■■■- ^ -■ - ^7^ 



344. The EUiott Forceps. . ._. 577 

346. Forceps ^Held as" They Would be Applied in L. O. A., R. O. P. and L. O. T. 



Positions 5°3 

347. Forceps Held as They Would be Applied in R. O. A., L. O. P. and R. O. T. 

Positions 5o3 

-uS. Introduction of Left Blade ......... 5»o 

\lq Incorrect Method of Holding the Forceps Blade During Introduction 587 

350! Correct Method of Holding the Forceps Blade During Introduction. Only 

the Tips of the Fingers are Used 587 

351. The Guiding Hand Protects the Cervix 588 

^52. Introduction of Right Blade ■ • • • ■ • • ■ • • • • • - ■•-•••• 5^9 

353. Locking of Forceps Made Possible by Rotating Handles Around Each Other 593 
354". Latest Modification of Tamier Forceps 596 

355. Traction with the Tamier Forceps 59^ 

356. Incorrect Method of Making Traction 599 

357. Correct Method of Making Traction with the Tamier Forceps 599 

358. Same Case. Traction Apparatus has Been Removed and the Head is Being 

Delivered as in the Ordinary Operation. 600 

359. Posterior Rotation of Head into the Hollow of the Sacrum 602 

360. Application of Forceps in R. O. P. Position. Head Poorly Flexed 603 

361. Application of Forceps in R. O. P. Position. Flexion Produced by Raising 

the Handles 604 

362. Application of the Forceps in Face Presentation 605 

363. Forceps xA.pplied to the After-coming Head 607 

364. Bimanual Version in Vertex Presentation. . 613 

365. Bringing Down Foot the Wrong Way 614 

366. Bringing Down Foot the Right Way ^i5 

367. Traction Correctly Made on Anterior Foot 616 

368. Traction is Incorrectly Made on Posterior Foot 617 

369. Bimanual Version in Vertex Presentation 618 

370. Grasping the Thighs and Buttocks During Extraction 620 

371. Podalic Version. Release of the Posterior Arm 621 

372. Podalic Version. Release of the Anterior Arm 623 

373. Wigand-]Martin-Winckel Combined Method 624 

374. ^Manoeuvre of Mauriceau 625 

375. Method of Mauriceau 626 

376. Extraction of the Head. Manoeuvre of Champetier de Ribes 627 

377. Prague Manoeuvre in Posterior Position of the After-coming Head 628 

378. External Version. Photograph of an Actual Case 630 

379. External Version. The Right Hand Brings Down the Head While the Other 

Lifts the Breech 632 

380. External Version. The Long Axis of the Foetus Has Left the Transverse 

Diameter of the Uterus and Version is Accomplished 632 

381. Method of Holding the Foetus in Position After External Version 633 

382. Vertex Presentation. Podalic Version Aided by External Pressure 634 

383. Caesarean Operation. High Incision in Median Line 641 

384. Caesarean Operation. Extraction of the Child, Fundus Brought Through 

Incision 642 

385. Caesarean Operation. First Layer of Sutures 643 

386. Caesarean Operation. Second Layer of Sutures 643 

387. Cesarean Operation. Utems Held by Assistant for Placing of Sutures 644 

388. Caesarean Operation. Suturing the Skin edges with Silkworm Gut 645 

389. Porro Operation. Utems Amputated Above Elastic Ligature, Which is Placed 

on the Lower Segment 648 

390. Extraperitoneal Caesarean Section, Showing Anatomical Relations of Peritoneal 

cul de sac, Bladder and Left Side of Utems 650 

391. Extraperitoneal Caesarean Section. Incision of Lower Segment After Pushing 

Back the Peritoneal cul de sac 651 

392. Galbiati's Falcetta 653 



XX ILLUSTRATIONS 

393. Veins of the Prevesical Space. Front View of the Bladder and Dorsal Surface 

of the Clitoris, the Right Cms of Which, as Well as the Right Side of the 
Pelvis, Has Been Cut Away 654 

394. Separation, with Injury to Soft Parts, Prevented by Pressure over Trochanters 656 

395. Pubiotomy, Doderlein's Method 658 

396. Pubiotomy, Open Method; Passing the Saw-carrier 659 

397. Pubiotomy, Open Method; the Chain Saw in Use 660 

398. Garrigues's Symphysiotomy Bandage 661 

399. Simpson's Perforator 666 

400. Perforation. An Assistant Holds the Head Firmly in Position 666 

401. Cranioclast of Braun and Method of Using 667 

402. Application of the Cranioclast in Brow Presentation. An Assistant Holds 

the Right Blade Well Back and to One Side, While the Operator Applies the 
Other Blade over the Face 668 

403. Cranioclast Applied and Handles Screwed Together 669 

404. Tarnier's Cephalotribe 671 

405. Tarnier's Basiotribe . . 672 

406. Use of the Tarnier Basiotribe. Introducing the Left Blade and Locking it 

to the Perforator 673 

407. Tarnier's Basiotribe. Introduction of P.ight Blade 673 

408. Tarnier's Basiotribe. Crushing of Occiput 674 

409. Tarnier's Basiotribe. Extreme Compression 674 

410. Basiotribe Extraction 675 

411. Aspect of Fetal Head Extracted by Means of the Basiotribe 676 

412. Scissors of Dubois and Crotchet of Braun 677 

413. The Use of Braun's Hook 678 

414. Assistant Holds Handle of the Crotchet During the Use of Scissors 679 

415. Extraction of the Fetal Body After Decapitation 680 

416. Embryotomy, Oblique Section 681 

417. Massage of the Breast 713 

418. Extension of Infectious Processes in the Breast. (In color) 718 

419. Treatment of Mammary Abscess. Good Direction of Incision 721 



OBSTETRICS 

NORMAL AND OPERATIVE 

PART I 
PREGXAXXY, LABOR AND THE PUERPERIUM 

CHAPTER I 

CHANGES IN THE MATERNAL ORGANISM RESULTING 
FROM PREGNANCY 

I. Local Changes. 2. General Changes 

By pregnancy or gestation is meant the period extending from con- 
ception to the beginning of labor. Since we can never know the exact 
date of conception, even though the date of fruitful intercourse be known, 
the exact duration of pregnancy in a given case cannot be computed, 
but the definition here given is the only one possible in the present state 
of our knowledge, and is, for all practical purposes, sufficient. 

Under ordinary circumstances the ovum and spermatozoon meet in 
the Fallopian tube and it is there that the fertilization of the ovum occurs. 
\\'ith the meeting of these two elements begins the drama of pregnancy 
and labor, than which there is no more interesting subject in the whole 
range of natural science. 

It begins indeed, with a striking and wonderful phenomenon which in 
the present state of our knowledge is beyond the limits of explanation or 
interpretation. The mere presence of the fertilized ovum, which, so far 
as we can see, is a mere guest, a separate organism, receiving nutriment 
and oxygen from the maternal blood, but without other demonstrable con- 
nection with the mother, inaugurates in the maternal organism a series 
of changes far-reaching and profound, which we endeavor to group and 
describe under the term pregnancy. 

A description of pregnancy, then, means a description of the changes 
in the maternal organism that follow conception. 

What are these changes ? They may be divided into two classes : local 
and general. Let us begin with those that are most characteristic, and 
most important from a clinical and diagnostic point of view — the local 
changes, and first of all the change in the uterus. 

Changes in the Uterus — This organ, which, at the beginning of 
pregnancy is about three inches in length with a transverse diameter of 

I 



2 PREGNANCY, LABOR AND THE PUERPERIUM 

about two inches and an anteroposterior diameter of about an inch and 
which at that time weighs about 50 grammes and Hes entirely within the 
pelvic cavity, must become large enough to contain the mature foetus, the 
new-born child, its fundus rising to the ensiform cartilage, its bulk increas- 
ing until it not only fills but greatly distends the abdominal cavity, and its 
weight reaching 1000 grammes. We need not marvel that an ancient 
writer, contemplating this transformation, cried out, " Ein Wunder der 
Natur ist der menschliche Uterus ! " 




Fig. I. — Xon-pregnant uterus. 

How is this change brought about? Physiology does not answer the 
question. The increase in size does not result from distention from 
within, as popularly supposed, and as taught by the older writers. That 
this is true is shown by the fact that the uterus enlarges in extra-uterine 
pregnancy, as well as in pregnancy that is normal. The enlargement is 
due to a hypertrophy of all the uterine structures, the so-called eccentric 
hypertrophy. It is greatest in the first four months in which the uterus in- 
creases threefold in thickness, i.e., it attains a thickness of about two and a 
half centimetres (2.5 cm.). During the latter half of pregnancy it increases 
enormously in area but becomes much thinner — thinner even than it was 



CHANGES IN THE MATERNAL ORGANISM 3 

before pregnancy began. In some cases, especially in women who have 
borne many children, the fetal parts are felt with startling distinctness, as 
though through a covering of paper. There is some dispute as to whether 
the uterus is distended by the foetus during the latter months of pregnancy. 
It is not probable that this is the case except under abnormal conditions, 
e.g., hydramnion or multiple pregnancy. According to Krause, the capac- 
ity of the uterus is increased 519 times during pregnancy. 




Fig. 



-Uterus at time of delivery. 



The hypertrophy of the pregnant uterus embraces all the component 
parts ; muscles, vascular system, connective and glandular tissue, and 
mucous membrane ; also the lymphatics and nerves. 

The uterine bulk is composed chiefly of muscular tissue. Let us con- 
sider first the changes in the muscle. They consist chiefly in hypertrophy 
of individual muscular cells already present in the virgin uterus. New 
cells play but a comparatively unimportant part in the process. It is 
interesting to note that the individual cells are not destroyed during 



4 PREGNANCY, LABOR AND THE PUERPERIUM 

involution, but remain ; perliaps to form the nuclei of subsequent develop- 
ment in a later pregnancy. The fibres of the pregnant uterus are estimated 
to be ten times as long as in the unimpregnated condition, and propor- 
tionately increased in width. Thus does nature provide for the strenuous 
work which the uterus will have to perform at the time of labor. 




Fig. 3. — Non-striated muscle of the uterus, a, fibre of non-pregnant uterus; b, fibre of the pregnant 
uterus; c, cross-section of fibres of the pregnant uterus. 



The muscular fibres of the cervix undergo moderate hypertrophy but 
to a less extent than those of the body of the uterus. There is, however, 
a relatively greater development of the elastic tissue. Thus does nature 
afiford provision for the dilatation that is indispensable to the progress 
of labor. 

The hypertrophy of the uterus is greatest at the fundus. This is 
vividly appreciated by every one who has had occasion to make the uterine 
incision in the Caesarean section. It is well shown in the accompanying 



CHANGES IN THE MATERNAL ORGANISM 5 

illustrations. Note that the tubes and round ligaments which are ordinarily 
given ott from the uterine Gornea are, in advanced pregnancy, given off 
at some distance below showing the relatively great increase in growth 
at the fundus. The round ligaments, too, which are an integral part of the 
uterine muscle and which serve to limit the ascent of the uterus during 
labor, are much hypertrophied, so much indeed that in certain cases of 
delayed labor they may be plainly felt and even seen through the abdominal 
wall, as large tense cords running obliquely downward at the sides of the 
uterus (Figs. 4 and 5). 

Fig. 4 Fig. 5 



Fig. 4. — Case of brow presentation with threatened rupture of uterus. Round hgaments clearly- 
felt and seen through abdominal wall. 
Fig. 5. — Overstretching due to oblique position. Both round ligaments perceptible. 

Ahlfeld has called our attention to the fact that when the placenta 
is posterior the tubes converge anteriorly, and vice versa. It has been 
shown, however, that this rule is not of universal application. 

The MuscuLx\ture of the Pregnant Uterus. — The arrangement 
of the muscular layers and fibres of the uterus during pregnancy is very 
complex and has been the subject of unending study and discussion. 
Bayer, in Germany, and Helie, in France, have been untiring workers 
in this field, and it is to them that we owe most of our knowledge of 
the subject, which, however, is yet far from exact. 



6 PREGXANXY, LABOR AND THE PUERPERIUM 

To summarize briefly, we may, in a general way, divide the muscular 
tissue of the uterus into three layers. 

1. An external layer, very thin and closely united with the peritoneum. 

2. A middle layer which comprises the bulk of the uterus, and which 
consists of longitudinal and circular fibres intimately blended in an arrange- 
ment complex and difficult to follow. The circular fibres, however, 




L 

Fig. 6. — The musculature of the pregnant uterus, dissected and seen from the side. (Luschka.) 
res., bladder; ur., ureter; vag., vagina; ^ori., vaginal portion; lig. rot., round liganient; lig. ov.^, ovarian 
ligament; izt6., Fallopian tube; m. sup., superficial muscular layer; 



med., middle muscular layer. 



surround the blood-vessels, nature's provision for the prevention of 
hemorrhage. 

3. An internal layer of circular fibres concentrically arranged about 
the internal os and the uterine ends of the tubes (Figs. 6, 7, and 8). 

The retractile function of the uterus is a property not found in other 
muscular organs and its mechanism is not clear. Hence it is not strange 
that the muscular arrangement seems complex even to skilled pathologists 
and laboratory workers. 

Other Changes. — For the nutrition and development of this mass of 



CHANGES IN THE MATERNAL ORGANISM 7 

newly- formed muscle, there must be a corresponding increase in the 
vascular supply, and thus we find arteries and veins, especially the latter, 
greatly hypertrophied. This greatly increases the volume of venous blood 
and accounts for the frequency of varicose veins, phlebitis and emboli in 
pregnancy (Fig. 9). 

With all this, there is inevitably an increased activity of the lymphatic 
system and an enlargement of the lymphatic glands. It is this relatively 
enormous increase in the venous and lymphatic supply that accounts for 





I up 



Fig. 7. — The musculature of the pregnant uterus, front view. (Helie.) The peritoneum has been 
dissected off and the bladder separated from the uterus and turned down. U, the Fallopian tubes; 
Ug. r., the round ligaments; ves., the bladder. 



the added susceptibility of the lying-in woman to the transmission of 
infection, and for the rapidity with which it sometimes spreads. 

The nervous supply is also more highly developed, the great cervical 
ganglion becoming more than twice its usual size. This serves to account 
for the increasing irritability of the uterus as the patient approaches term, 
and undoubtedly helps to determine the final onset of labor. 

The connective tissue of the uterus and especially, as already noted, 
that of the cervix, is also hypertrophied and is much softened by the serous 
infiltration that goes with the increased vascular and lymphatic supply. 
Thus does nature provide not only for the softening and dilatation of the 



8 



PREGNANCY, LABOR AND THE PUERPERIUM 



cervix and lower uterine segment that are so necessary during the latter 
weeks of pregnancy and the early part of labor, but also for the various 
and comparatively rapid changes in the size and shape of the uterus that 
constitute so prominent a part of the parturient process. 

The whole uterus, then, is softer than in the non-pregnant condition ; 
but this softening is much more marked in the cervix and lower uterine 
segment. As w^e shall see in the next chapter, these facts help us in 
the diagnosis of pregnancy. It is the softening of the lower 



makmg 




Fig. 8. — The submucous muscular layer of the pregnant uterus. (Helie.) 



Uterine segment that enables us to elicit Hegar's sign, the most character- 
istic of all the signs of early pregnancy. 

But the muscular tissue, the blood-vessels and the lymphatics are not 
the only tissues concerned. As the student has seen in his embryological 
studies the mucous membrane of the uterus becomes hypertrophied to 
provide means of shelter and nutrition for the fertilized ovum, and thus 
are formed tlie decidua vera and the decidua reflexa. The hypertrophied 
mucous membrane fills the cervical canal with a tough plug of mucus. 
Sometimes the excretory ducts of the cervical glands become obstructed, 

the so-called Ovula-Nabothi. 



giving rise to hard nodules 



CHAXGES IX THE MATERXAL ORGAXISM 9 

The Growth of the Uterus. — Toward the end of the third month 
the fundus can be felt on a level with the symphysis and during the 
remainder of pregnancy it rises by regular gradations until about three 
weeks before delivery, when it fills the abdominal cavity and reaches, or 
nearly reaches, the ensiform cartilage, only to sink to a lower level as 
labor approaches. 

The clinical evidences of this growth will be considered in the next 
chapter in connection with the diagnosis and clinical phenomena of 
pregnancy. 




Artena utenna 







Vena uterina 




Vena 
spermatica 



Arteria 

spermatica 



Plexus vaginalis 



Fig. 9. — Vascular system of the uterus. 

Changes in Shape and Position. — But it is not only in size that 
the uterus changes ; there are certain changes in shape and position 
that must not be forgotten. 

The first noticeable change is that the lower uterine segment fills out. 
making the body of the uterus spherical rather than pear-shaped and 
causing an apparent shortening of the cervix. This is one of the most 
important of the early signs of pregnancy, as we shall see in the next 
chapter. 

Later, however, as the fundus rises in the abdominal cavity, the uterus 
assumes an oval form. Thus we have the uterus first pear-shaped as in 



10 



PREGNANCY, LABOR AND THE PUERPERIUM 



the virgin state, then spherical, and finally oval (Figs. lo, ii and 12). 

The uterine ovoid, however, does not remain symmetrical throughout 
pregnancy. In the first half of pregnancy it is larger and thicker upon 
the side which contains the ovum, another sign of pregnancy; not a 
very positive one, it is true, but of some value to the experienced examiner. 
It is not until the second half of pregnancy that the other side of the 
uterus is filled out by the enlarging ovum (Fig. 13). 

The normal position of the pregnant uterus is one of anteversion, and 
as the body of the uterus increases in size and weight it develops a tendency 
to sink forward and thus make more acute the angle between body and 
cervix. This tendency is favored by the softening of the lower uterine 
segmer.t already noted. 




Fig. 10. — Pear-shaped uterus. 



Fig. II. — Spherical uterus. 



This symptom disappears of course as the uterus rises into the abdom- 
inal cavity but promptly reappears after delivery and persists normally 
durmg the lying-in period. When exaggerated it may cause retention 
of lochia with alarming symptoms, as we shall see when we come to study 
the pathology of the puerperium. 

Ltcrine Inclination. — The uterine mclination or the direction of the 
long axis of the uterus varies with the condition of the abdominal walls. 
In primiparse with firm and resistant walls the uterus may rest upon the 
spinal column, its axis being directed even farther backward than that 
of the superior strait. In these cases the centre of gravity is so far back 
that the patient, in order to maintain her equilibrium, throws the head 
and shoulders backward instinctively, adopting a sort of militar}^ attitude 
familiar even to the laity. In multiparse with lax and atrophied abdominal 
walls the uterus falls forward. Sometimes, especially in cases of con- 



CHANGES IN THE MATERNAL ORGANISM 



11 



tracted pelvis, when the presenting part cannot enter the brim, or when 
the intra-abdominal space is restricted, this tendency to fall forward is 
much exaggerated, the fundus actually reaching a lower level than the 
symphysis — pendulous abdomen, Hiiiigchaiich of the German clinics. In 
primiparse the uterus points directly forward, Spitzhauch. 

These conditions are described and illustrated in connection with the 
subject of pelvic contraction. 

Right Lateral Obliquity of the Uterus. — In advanced pregnancy the 
fundus uteri is usually found, not in the median line as one would at 
first thought suppose, but on the right side in the region of the liver, though 





Fig. 12. — Ovoid uterus. 



Fig. 13. 



-Uterus at successive months. 
(After DeLee.) 



it may be found in the median line or even on the left side. This fact soon 
becomes familiar to every physician. 

Uterine Torsion. — Not only does the uterus as a whole incline some- 
what to the right but it is also twisted to the right. In other words, it is 
rotated on its long axis so that its anterior surface does not look directly 
forward but somewhat to the right. 

What is the cause of uterine obliquity and torsion? Both are usually 
attributed to the position of the rectum and sigmoid flexure on the left 
side of the pelvis and the consequent shortening of the right oblique 
diameter. An additional factor in the case of right uterine obliquity is, 
perhaps, the fact that most patients sleep upon the right side. 

Importance of These Facts. — Both facts are of clinical importance. 



12 PREGNANCY, LABOR AND THE PUERPERIUM 

For example if, in the performance of the Csesarean section, the operator 
makes his incision exactly in the median line and does not, before making- 
it, instruct his assistant to rotate the uterus to the left, he will find his 
uterine incision not where he intended to make it, in the median line, but 
well to the left side which, as we shall see when we come to take up that 
subject, is highly undesirable. 

Again the left ovary and tube are much nearer the median line and 
much more accessible to palpation than are the right. 

And finally, in estimating the period of pregnancy that has been 
reached in a given case with a view perhaps to determining the maturity 
of the foetus and the wisdom of the induction of labor, the fundus should 
be carried to the median line in order that a clear conception of its true 
height may be obtained, its distance from the symphysis measured, and 
the length of the foetus approximately determined. 

Relations of the Pregnant Uterus. — A\^ith the increase of size 
and the change of position which the uterus undergoes during pregnancy 
its relation to surrounding structures is of course radically changed. In 
front is the bladder which during pregnancy becomes at least in part an 
abdominal rather than a pelvic organ. By virtue of its attachment to the 
anterior uterine wall it is carried far upward and somewhat to the right. 
The latter fact is due to the familiar right obliquity of the uterus. This 
changed relation of bladder and uterus finds an important practical appli- 
cation in the performance of the Csesarean section. If the incision is too 
low or if the bladder is not emptied before the operation the result may 
be easily imagined. 

The ascending, transverse, and descending colon encircle the uterus 
like a hood or frame. The small intestines, too, are found at the fundus 
and at the sides of the uterus ; seldom in front. Now and then, however, 
a stray loop may be found anteriorly, another fact of practical importance 
in connection with laparotomy during pregnancy. 

In front the uterus is in direct relation with the abdominal wall and 
behind it rests upon the spinal column, these positions varying of course 
with the position of the patient, whether standing or recumbent. 

Changes in the Adnexa. — With the growth of the uterus the folds 
of the broad ligaments become separated and owing to the widening of 
the uterus the tubes hang close to its sides instead of branching out as 
in the non-pregnant condition. 

Changes in the Cervix. — During the latter months of pregnancy there 
is apparently considerable shortening of the cervix. Whether this shorten- 
ing is real or only apparent has been for many years a matter of controversy 
— the Ccrvixfrage of the German writers. 

\Yq shall see in studying the physiology of labor how during that 
process the body of the uterus becomes divided into two parts, one 
thin and dilatable, the lower uterine seo^ment. the other thick and con- 



CHANGES IX THE MATERNAL ORGANISM 13 

tractile, these two parts being separated by a muscular ridge known as 
the contraction ring. 

\\'riters upon this subject are divided into two camps. On the one side 
are those who maintain that the shortening of the cervix is real and that 
with the advance of pregnancy the cervix is taken up to form the lower 
uterine segment. On the other side are those who maintain that the 
cervix has nothing to do with the formation of the lower uterine segment 




Fig. 14. — Relation of the colon to the pregnant uterus. 

and that cervical shortening during pregnancy is only apparent, being the 
result of fusiform dilatation or of obliteration of the anterior lip by the 
pressure of the fetal head. 

The reader will notice at once that in these cases the shortening is 
apparent rather than real and that, if the head is pushed up, the canal will 
be as long as before. On the other hand there is no doubt that in cases 
of extreme distention from any cause, e.g., hydramnion or twin pregnancy, 
the canal is much shortened and sometimes practically obliterated. This 
I have many times had occasion to verify. 



14 



PREGXAXCY, LABOR AND THE PUERPERIUM 



The majority of writers at present appear to favor the theory of the 
non-shortening of the cervix, but the question so aptly asked by 
Ohlshausen, " \\'hy should so homogeneous a structure as the corpus 
uteri be divided during pregnancy into two parts so radically different 




^^fe; 






Fig. 15. — Pregnant uterus at the third month, posterior aspect. 

in function as the upper and lower uterine segments ? " remains unan- 
swered. 

^ The Cervix at or Near Term. — Whatever views we may hold as to 
this matter we must not forget to study carefully the important practical 
topic of the comparative shape, size, and degree of dilatation of the cervix 
and its canal during the latter weeks of pregnancy. 

In primipar?e the canal is cylindrical or perhaps spindle-shaped. The 



CHANGES IN THE MATERNAL ORGANISM 15 

external os is firm in consistence and punctiform in shape. It is usually 
closed, or perhaps barely admits the tip of the finger though not very 
infrequently the finger may be passed through both the external and the 
internal os without difiiculty. 

In multipar?e the conditions are quite dififerent. The external os is 
represented not by a point but by a transverse slit with a notch at either 
end — the usual slight but plainly appreciable bilateral tear almost always 
found in primiparse. Exceptions to this rule are rare but they do occur. 




\ 




Pig. i6. — Ovoid uterus of advanced pregnancy. Adnexa converging anteriorly. 

Now and then we find a case in which the tear is not present and in. which 
the cervix cannot be distinguished from that of a primipara. 

The internal os is smaller and more tense than the external os. It 
is circular but it is not closed. Indeed it almost always admits one or two 
fingers without difiiculty, and its firm and resisting ring presents a marked 
contrast to the relaxed and yielding margins of the external os. The canal 
taken as a whole resembles an inverted funnel, the internal os being much 
smaller than the external whose resistance has been partly destroyed by 
previous labors. 

The reader should be careful to familiarize himself not onlv bv stud\' 



16 



PREGXAXCY, LABOR AND THE PUERPERIUM 



but by actual practice with the condition of the cervix in primiparae and 
multipar^e during the latter weeks of pregnancy. It is a subject of great 
practical importance and one to which we shall frequently have occasion 
to refer. 

Changes in the Vagina. — The mucous membrane of the vagina too 
becomes congested and infiltrated and the purple color thus caused is one 
of the corroborative signs of pregnancy. Its secretion is increased, another 
corroborative sign. This secretion, profuse, acid and thickened with 
epithelial debris, soon becomes familiar to the obstetrician. According to 
Doderlein this acid secretion inhibits bacterial development. The surface 



Internal os 



External os 




Anterior 
vaginal vault 



Fig. 17. — Seventh month. Head high, anterior vaginal vault preserved. 

of the mucous membrane is roughened and the rugae become more marked. 
The purple pouting mucous membrane projects from the vagina, simulating 
rectocele and cystocele, presenting a picture of advanced pregnancy very 
familiar to the observing physician. 

The vulva, perineum and pelvic floor become softened and infiltrated 
and there is a general downward sagging of the pelvic floor — the '' pelvic 
floor projection " of Hart and Barbour. 

Changes in the Pelvic Joints. — Even the pelvic joints, the pubic 
symphysis and the sacro-iliac articulations, become infiltrated, softened 
and more movable than in the non-pregnant state. Doubtless these changes 



CHANGES IX THE MATERNAL ORGANISM 



17 



have helped to turn the scale in favor of the patient in many a doubtful 
case. DeLee has shown by careful measurements that toward the end 
of pregnancy there is an actual enlargement of the pelvis. 

Changes in the Abdominal Walls. — In the latter part of pregnancy 
and especially in cases attended by much distention or in women who 
have borne many children the abdominal walls become thin, atrophied 
and bloodless. This too is especially noticeable to one doing his first 
Csesarean section. Oftentimes it is not necessary to tie a vessel in these 
cases. One notices, too, how^ distensible the wall is and how one can stretch 
a three- or four-inch incision with a finger hooked in each end until it is 
quite large enough to permit the extraction of a child. It seems almost as 



Internal os 



External os 




Fig. i8. — Shows obliteration of anterior lip of cervix, head having entered the pelvis. Anterior vaginal 

wall pressed down. 

though kind nature had made provision for the necessities of the operation. 

With the ascent of the uterus the navel gradually ceases to be a 
depression and w^ith the beginning of the seventh month or a little later 
it begins to protrude. 

Such in brief are the outlines of the changes in the generative organs 
that follow^ conception. They can be found in greater detail in works 
devoted to embryology and to the theory rather than the practice of 
obstetrics. To attempt to master all the minutiae of the subject would 
be a tedious and, for the non-specializing student, perhaps a profitless task. 

All should know the main facts, however, and when these facts are 
studied and taught with appreciation and intelligence, as afi:'ording the best. 
2 



18 PREGXAXCY, LABOR AND THE PUERPERIUM 

indeed the only rational, basis for much of obstetric diagnosis and treat- 
ment, the work becomes a delight in itself. 

But the effects of pregnancy are not felt by the pelvic organs alone. 
Every tissue, organ, or function of the body is or may be affected. It is 
therefore necessary for us to consider the influence of pregnancy upon the 
organism in general. 

General Changes in the Maternal Organism. — Pregnancy is not a 
disease. Indeed it might not be amiss to call it the highest kind of health ; 
the highest development of the normal physiological capacity of 
womanhood. J\Iany writers say that pregnancy is a test of the organ- 
ism, and this is true ; if the organism is sound it responds to the 
test and, despite much inconvenience and some temporary sacrifice and 
suffering, the patient emerges from her period of trial not only uninjured 
but benefited. It is a matter of common observation that women who have 
had several or perhaps many children are usually in better health than 
their less fortunate sisters. It is the subsequent care of the children under 
the strenuous and unnatural conditions of our modern life that sometimes 
makes motherhood seem almost too great a burden. 

But we must admit that the organism is not always equal to the strain ; 
that it not infrequently breaks down at its weakest point. This may 
happen during the early months of pregnancy, before it has become 
adjusted to its new burden, or perhaps later on as the demands upon the 
organs of elimination increase. Untoward accidents may occur or some 
intercurrent or complicating disease may suffice to turn the scale in the 
wrong direction. 

Thus we see that the pathology of pregnancy affords a wide field for 
study. But this will come later. Let us consider here only those changes 
that mark a pregnancy approximately normal, beginning at the fountain 
head, i.e., wath the heart and general circulation. 

Changes in the Heart and Circulatory Apparatus. — For a long time 
it was generally believed and taught that pregnancy is normally accom- 
panied by a certain amount of cardiac hypertrophy and some still hold this 
opinion. It is probably incorrect. Doubtless it originated in the fact 
that the apex beat is often displaced by the ascending uterus. The asser- 
tion that the heart has more w^ork to do during pregnancy and therefore 
must hypertrophy is to be met by the reply that nature has methods 
of adjustment and compensation that we do not understand. Moreover, 
careful measurements have failed to establish any hypertrophy. (Bumm.) 

To my mind it is sufficiently clear that there is no considerable hyper- 
trophy of the heart in pregnancy. It is certain that the normal heart 
of a healthy woman is not usually damaged by pregnancy, and many 
women with organic heart trouble sustain the ordeal of pregnancy and 
labor without bad results. 

It is important, however, for the reader to remember that an entirely 
innocent heart murmur often co-exists with pregnancy. This fact, often 



CHANGES IN THE MATERNAL ORGANISM 19 

overlooked in the text-books, soon becomes familiar to the house surgeons 
of maternity hospitals and should be known to all physicians, that needless 
alarm may be prevented. A systolic murmur at the base is often present. 
According to DeLee it is usually h?emic in origin but may be due to dis- 
placement. Perhaps the former would be the case more often in early 
pregnancy, the latter in advanced pregnancy. 

It is impossible to speak dogmatically with regard either to the quantity 
or the quality of the blood in pregnancy. According to Fries the total 
quantity of blood is not increased. Others dispute this. Williams and 
his assistants report that the blood-pressure is increased. This is denied 
by Hirst and others. 

As regards the composition of the blood there seems to be little demon- 
strable change. It was formerly taught that there is a hydrsemia or, 
as it is sometimes called, " physiological anaemia," during pregnancy. This 
idea, which is a priori improbable, has not been confirmed by modern 
investigators. That there is often a transient anaemia, however, during 
the early months is a matter of common observation. 

On the whole the result of much work by different investigators has 
given us little information. The number of red corpuscles and the amount 
of haemoglobin are about the same as in the non-pregnant condition. 
Zangemeister and Peyer have noted a decreased alkalinity of the blood. 
To my mind this denotes a slight suboxidation which, as stated elsewhere, 
I believe to be a common accompaniment of pregnancy. Our methods of 
examining the blood still leave much to be desired and there are doubtless 
changes which cannot be detected by our present methods. 

Neu has observed an increase in the adrenalin content, and various 
others an increase in the cholesterin content. 

During the latter months of pregnancy there is a leucocytosis which 
becomes quite marked during labor and continues, as we shall see later, 
during the first few days of the puerperium. The exact cause of this is 
not clear but the fact should not be forgotten since in a doubtful case the 
demonstration of a leucocytosis might lead to an unwarranted diagnosis 
of infection and to undeserved censure of the attendant. 

Partly as the result of pressure, but chiefly as the result of the great 
hypertrophy of the venous channels in the uterine wall and the attendant 
enormous increase in the venous return, the circulation in the lower limbs 
is embarrassed and varicosities are so common that unless of unusual 
size they attract little attention. In some cases, however, they are not 
only the cause of great discomfort but a source of actual danger since 
rupture with severe hemorrhage may occur. 

Hemorrhoids, which are nothing more than varicose veins of the 
rectum, are very common in pregnancy and varicosities of the vulva may 
reach an enormous size. It is important to remember that congestion 
and varicosities of the mucous membrane of the bladder may cattse marked 
changes In the urine. These we will presently consider. 



20 PREGXAXCY, LABOR AND THE PUERPERIUM 

Sometimes the interference with the venous return causes marked 
swelHng of the feet and legs, a condition which may be mistaken by the 
unwary for an oedema due to tox?emia. The presence of enlarged veins, 
however, and the fact that the swelling promptly disappears if the patient 
is kept for a day or so in the recumbent position should suffice to settle 
the question. Moreover, the swelling caused by venous obstruction is 
often unilateral, which of course would not be the case in an oedema 
arising from some general condition. 

Elinor disturbances of the circulation, faintness, dizziness, palpitation, 
etc., are common in pregnancy, especially during the early months. They 
seem to accompany the anaemia and nervous depression so common at this 
time. In later pregnancy they are due to pressure of the growing uterus 
upon the stomach or diaphragm, or perhaps to toxaemia and suboxidation. 

Changes in the Respiratory Apparatus. — Toward the end of preg- 
nancy the excursions of the diaphragm are limited and the ascent of the 
fundus causes some compression at the base of the lungs. In cases of 
great distention, e.g., hydramnion or twin pregnancy, dyspnoea may be 
extreme, even necessitating the induction of labor. According to Dohrn 
there is usually a compensatory widening of the lungs. 

Zuntz and Williams claim that while the total amount of air inspired is 
increased there is no material change in the amount of oxygen consumed 
or of carbon dioxide given off. According to DeLee the respirations are 
increased in frequency (26 to 28) and the excretion of carbon dioxide 
is greater. The latter view seems to accord better with the fact that in 
pregnancy the maternal blood must oxidize a great excess of nitrogenous 
material in the processes of fetal and placental metabolism. 

There is in some cases a tendency to congestion of the nose and throat. 
The voice may be affected in singers. Laryngeal tuberculosis makes rapid 
progress. Typical attacks of bronchial asthma may occur, disappearing 
after delivery. The asthmatic condition, however, is probably a neurosis. 

Slight subjective dyspnoea is common in pregnancy. The patient is 
oppressed in crowded or ill-ventilated rooms and longs for the fresh air 
and the open country. I believe this to be due to suboxidation accom- 
panying a slight or unrecognized toxaemia. More pronounced dyspnoea is 
strongly suggestive of true nephritis complicating pregnancy. 

Changes in the Alimentary Canal. — Custom and convenience have 
often led to the inclusion of the vomiting of pregnancy among the ali- 
mentary changes, but it is usually, I think, a neurosis. Occurring at an 
early period of pregnancy and disappearing in a few weeks it is so common 
as hardly to be considered abnormal. We will consider it in connection 
with the diagnosis of pregnancy and again in connection with the 
pathology of pregnancy. 

Occurring in the latter months of pregnancy it is usually an evidence 
of toxaemia. In some cases it denotes impending eclampsia. Severe 
epigastric pain may also denote the outbreak of an eclamptic attack. 



CHANGES IN THE MATERNAL ORGANISM 21 

Ptyalism, or excessive flow of saliva, which is probably, also, of neurotic 
origin, will be described in connection with the management or with the 
patholog}' of pregnancy, as will also stomatitis, and the so-called longings. 
]Most of the symptoms and conditions occurring at this time, that are 
supposed to be of gastric origin, have nothing to do with the stomach at all. 

Constipation, so common as to excite little attention, is due partly to 
simple mechanical obstruction, partly to intestinal paresis from pressure, 
and partly to loss of power in the abdominal muscles from distention. 
This important subject will be discussed in connection with the management 
of pregnancy. 

Toward the end of pregnancy the liver is displaced upward and to the 
right while the stomach is pushed upward and to the left. This displace- 
ment is of clinical importance if one has occasion to map out these organs 
by percussion, but it is not usually productive of symptoms. Some 
patients are annoyed by heartburn. 

The careful and extended work of Hofbauer has shown that the func- 
tional overstrain to which the liver is subjected during pregnancy causes 
beginning fatty changes even in a large proportion of cases approximately 
normal. To my mind this is best explained as the result of the extra 
work required of this organ in the oxidation of the great nitrogenous 
excess of pregnancy. 

Probably these changes are the accompaniment of many cases of mild 
toxaemia not sufficiently pronounced to present typical symptoms. 

Jaundice, catarrhal inflammation of the bile ducts, and gall-stones are 
more common during pregnancy and will be considered in connection 
with its pathology. 

On the whole the changes in the digestive tract are not usually very 
pronounced. One is often astonished to see how in spite of the pressure 
of the enormously enlarged uterus upon all the abdominal viscera, and 
the demand upon the mother's reserve power to supply the needs of 
the growing foetus, her nutritional equilibrium is undisturbed and her 
general health perhaps even better than usual. 

Changes in the Glandular System. — Owing to the increased circula- 
tory activity, the lymphatic glands all over the body are hypertrophied. 
As already mentioned, this is especially true of those of the parametrium. 

V^ery interesting, though not as yet well understood, are the changes 
in the ductless glands. The thyroid gland usually undergoes moderate 
hypertrophy during pregnancy. Now and then there is marked enlarge- 
ment which, however, disappears after delivery. The significance of these 
changes is not known. The alleged relation of the thyroid gland and its 
secretion to the toxaemia of pregnancy and to eclampsia are discussed 
elsewhere. Personally I do not believe that it is a specific relation, but 
that if thyroid extract does good in this condition it is by its stimulating 
effect upon general metabolism and especially upon the oxidative processes. 

The suprarenal capsules become hypertrophied and, as noted above» 



22 PREGXANXY, LABOR AND THE PUERPERIUM 

there is an increase in the adrenaUn content of the blood. There is also 
an enlargement of the pituitary body. Why this should occur we do not 
know but it is clear that there is some unexplained relation ♦between 
the secretion of this gland, and uterine activity. The therapeutic value 
of pituitrin in selected cases in the stimulation of labor pains and its 
alleged relation to the secretion of milk are considered elsewhere. 

Changes in the Urine and Urinary Tract. — Careful examination will 
show that about ten per cent, of all specimens contain traces of albumen. 
Perhaps in one-half of these cases the slight albuminuria is due to transu- 
dation through the congested mucous membrane of the bladder, in other 
cases it is the result of admixture of leucorrhoeal discharge. 

As a general rule, however, the presence of albumen in quantities 
sufficient to be detected by the usual heat or nitric acid tests means that 
toxaemia is present, and if a careful examination is made symptoms will 
usually be found. This important subject will be carefully considered 
in connection with the pathology of pregnancy. 

The total quantity of urine is increased and its specific gravity dimin- 
ished. A diminished quantity indicates the death of the foetus. Aceto- 
nuria is common but its significance is not known. It was formerly sup- 
posed to indicate the death of the foetus but this idea has been shown to 
be erroneous. 

It is important to note that sugar is often found in the urine of preg- 
nancy. Using Fehling's test Williams found sugar in five per cent, of 
his cases in the last month, and it has been shown by other observers that 
sugar in small quantities is present much oftener in pregnant than in 
non-pregnant women. In most cases, however, the condition is one of 
lactosuria. It is milk sugar, not glucose, that is present, the condition being 
due to absorption from the breasts. Of course the clinical evidences of 
diabetes are absent. 

It was formerly taught that diabetes is common during pregnancy. 
This has not been my observation and I have no doubt that the idea arose 
from the fact that milk sugar is so often present. In case of doubt the 
polariscope will enable us to determine whether we have to deal with 
glucose or milk sugar. This subject is further considered in connection 
with the pathology of pregnancy. 

The output of urea is less in the pregnant than in the non-pregnant 
state. Just the opposite of what we would naturally expect. My attention 
was drawn to this fact long ago in examining the urine of out-patients 
at the New York Polyclinic. At that time certain writers held that a small 
excretion of urea was an Indication for the Induction of labor, and I have 
no doubt that many labors were unnecessarily Induced for that reason. 

\YKi\t the amount of urea nitrogen Is lessened that of the ammonia 
nitrogen and of the undetermined nitrogen is increased. The amino 
acids are present in abundance. 

On the whole the most significant and encouraging studies In the 



CHAXGES IN THE MATERNAL ORGANISM 23 

urinalysis of pregnancy have been those made in connection with the now 
familiar nitrogen partition. These have shown, not only that less urea 
nitrogen is excreted during pregnancy than at other times, but that the 
urine contains large quantities of nitrogenous substances in a state of 
incomplete oxidation. The clinical bearing of these facts will be discussed 
in connection w^th the toxaemia of pregnancy. 

The kidney may be dislocated into the pelvis by the pressure of the 
enlarging uterus. The ureters are swollen and sensitive and can be 
palpated with ease. The examining finger in the vagina feels the ureter 
where it passes over the pelvic brim. Compression of the ureters may 
convert a mild and previously unnoticed catarrh into a severe process 
just as pressure upon the bile ducts may do. Fortunately these things 
do not occur often. One wonders why they are not more frequent than 
they are. We will come to them again in connection with the pathology 
of pregnancy. 

As explained in the next chapter frequent urination is one of the 
most common symptoms of early pregnancy. Toward the end this returns 
and now it is an indication of approaching labor. Here of course it is 
due to the pressure of the head. It is more marked in primiparse, as in 
these cases the head usually descends into the cavity of the pelvis long 
before the beginning of labor. 

As already mentioned the mucous membrane of the bladder shares in 
the general congestion and the cystoscope shows varicose veins at the 
base of the bladder. In some cases there is a transudation through the 
congested membrane and a resulting albuminuria. This albuminuria, 
however, is intermittent in character and unaccompanied by symptoms. 

Varices of the bladder occasionally result in hsematuria which may 
give cause for much anxiety and even give rise to the suspicion of placenta 
praevia. 

Changes in the Skin. — With the increased activity of the general 
circulation and of the glandular system there is, in the latter months of 
pregnancy, an increased secretion of perspiration. The necessity for free 
elimination is very great at this time and nature seems to respond in this 
way to the increased tax upon her resources. This increased secretion 
continues and as we shall see becomes even more marked during the 
puerperium. 

Pigmentation of the breasts is so common and characteristic during 
pregnancy as to constitute a means of diagnosis and will, therefore, be 
considered in the next chapter. The same thing may be said of the familiar 
stri(F or Unece alhicantes, the result of distention of the skin. 

But pigmentation is not confined to the breasts. There is also the 
familiar pigmentation of the navel and linea alba. This does not appear as 
a rule until the sixth month. 

More rarely there is a development of single or scattered areas of 
pigmentation, especially about the face and neck — the chloasma of preg- 



24 PREGNANCY, LABOR AND THE PUERPERIUAI 

nancy. These areas are much Hghter in color than those of the breasts 
and liiiea alba but are sufficiently well marked to be the source of much 
annoyance to sensitive patients. Among the laity they are often called 
" liver spots " since they are popularly supposed to be due to some disorder 
of the liver. 

What is the cause of pigmentation in pregnancy? Wychgel has 
advanced the ingenious hypothesis that it is due to the presence of haemo- 
globin that has survived the destruction of the red blood-corpuscles that 
occurs in pregnancy. He claims to have demonstrated that the pigment 
contains iron. 

Toward the end of pregnancy there appear upon the surface of the 
abdomen and buttocks the stricF or lijiew albicantes, as they are called, 
short tapering bands of cicatricial tissue, pinkish or bluish-white in color, 
and depressed below the level of the surrounding skin. With the lapse of 
time they become a dead white in color and remain as silent witnesses of a 
previous pregnancy. They are not infallible witnesses, how^ever, since 
they may be the result of distention. For example, they are found in 
cases of overdevelopment of the breasts, and when the abdominal surface 
is distended by any large tumor, and they have been noticed upon the 
biceps of the athlete. They are of no great value in the diagnosis of 
pregnancy since by the time they become well marked the other symptoms 
are usually quite sufficient. They are, however, of great value as cor- 
roborative evidence of multiparity, that is of the fact that the patient 
has at some time been pregnant. 

Changes in the Mind and Nervous System. — Some patients experi- 
ence a feeling of exceptional well-being during pregnancy. In a much 
larger proportion of cases, however, there are, even in pregnancy approxi- 
mately normal, periods of depression which occur without apparent cause. 
The patient is depressed in spirits or perhaps has fits of irritability. Often 
she admits that she cannot explain the cause of her feelings. Cases of 
this kind are so common that they can hardly be considered abnormal. 
They usually occur in early pregnancy and doubtless represent the effect 
upon the nervous system of the anaemia and malnutrition so common at 
that time. With the advance of pregnancy they usually disappear. They 
are part of the price that woman has to pay for her share in the perpetua- 
tion of the race. In the event of strong hereditary predisposition, how- 
ever, true insanity may follow, as we shall see when we come to discuss 
the pathology of pregnancy. 

Changes in the Bones. — The proverbial toothache is doubtless due to 
the fact that calcium in large quantities must be supplied for the upbuild- 
ing of the foetus. Osteomalacia, rarely seen in this country, is an extreme 
instance of calcium deprivation, but there are probably intermediate forms 
not usually recognized. Deficiency in calcium has been held to be the 
cause of eclampsia. Calcium is an oxygen carrier and doubtless a 
lack of it predisposes to suboxidation. An unexplained phenomenon of 



CHANGES IN THE MATERNAL ORGANISM 25 

gestation is the production of the so-cahed puerperal osteophytes, newly- 
formed plates of bone on the internal surface of the skull. Their presence 
is not constant and nothing definite is known as to their origin or signifi- 
cance. They are not peculiar to pregnancy, however, as they have been 
found in syphilis and tuberculosis. 

General Nutrition and Metabolism. — As already noted patients are 
often more or less depressed, both mentally and physically, during the 




kk. 



^:^^'' 



Fig. 19. — Abdominal striae. 



early months of pregnancy. Ansemla and moderate loss of flesh are 
common. After the first few months, however, the organism seems to 
become accustomed to the new conditions, the patient begins to gain in 
weight, her color and general condition improve, and the improvement 
continues, barring accidents, until the end of pregnancy. 

It is a natural assumption that a process as profound and far reaching 
as pregnancy would be accompanied by metabolic changes easy to recog- 
nize, but this has not yet proved to be the case. Nature has here drawn 



26 PREGXAXXY, LABOR AND THE PUERPERIUM 

a veil which chnical study and laboratory research have alike failed to 
penetrate. 

The reader will already have noticed that there is marked difference 
of opinion as to such elementary matters as the quantity and composition 
of the blood, the character of the respiratory exchange, and the effect of 
pregnancy upon the heart and the blood-pressure. 

We have already referred to the fact that pregnant women excrete 
a relatively small amount of urea and this too in spite of the fact that 
there is an excess of nitrogenous waste to be disposed of. This, as well 
as the relatively very rapid increase in weight during the last few weeks 
of pregnancy, seems to indicate a storage of nitrogen to provide for the 
active necessities of fetal and placental metabolism. The great burden 
of oxidizing this excess of nitrogen and of disposing of v/aste products 
falls upon the liver and kidneys, especially the former. This is shown, 
not only by theoretical considerations and by what we have recently learned 
of the work done by the liver in the process of oxidation, but also by the 
results of autopsies in those cases in which these organs have finally 
broken down under the strain of a profound toxaemia, finally resulting 
in the outbreak of eclamptic convulsions. 

It is evident that, in order to keep pace with the enormous increase in 
nitrogenous metabolism that is an inevitable accompaniment of pregnancy, 
the oxidative processes must be kept at the highest pitch of efficiency. 
]My own views upon this subject, w^hich differ radically from those of 
other workers in this field, are given in connection with the toxaemia of 
pregnancy. 



CHAPTER II 

THE DIAGNOSIS AND CLINICAL PHENOMENA 
OF PREGNANCY 

The diagnosis of pregnancy is one of the most important subjects in 
medicine and one of the least understood. Mistakes are constantly made, 
even in cases perfectly normal. 

In my opinion, difficulty in diagnosis is due to three factors : 

1. The failure to distinguish between the presumptive and the positive 
evidences of pregnancy. This is chiefly the result of defective text-book 
classification. 

2. Unfamiliarity with the bimanual examination, and with the size, 
shape and consistency of the normal uterus. This is due to defective 
g}-n2ecological training. 

3. Unfamiliarity with the bimanual examination of early pregnancy, 
and with the physical diagnosis of advanced pregnancy, especially the 
mapping out of the fetal parts and the auscultation of the fetal heart. 
This is due to the lack of proper obstetric training the world over. I do 
not mean that the training is not often good, but that there is not enough 
of it. The physical diagnosis of pregnancy is certainly as important as 
that of the heart and lungs ; indeed, from the standpoint of results, it is 
more important. But how little attention it receives ! I have often been 
impressed by the fact that the best diagnosticians that I meet are the 
house surgeons in maternity hospitals. 

In considering the diagnosis of pregnancy most writers divide preg- 
nancy into three periods of three months each, three trimesters, as they 
are often called. This, it seems to me, serves only to complicate the 
situation. Pregnancy should not be divided according to months, but 
according to its clinical characteristics. More rational is the division 
adopted by the French writers, vis., the division of pregnancy into two 
parts ; the first half, or the period of doubt, and the second half, or the 
period of certainty. To be sure this requires some qualification. In 
normal cases, the experienced accoucheur is seldom in doubt after the 
first six weeks or two months, while in cases complicated by large tumors 
he may be obliged to reserve his decision until the patient is far advanced 
in pregnancy. For the great majority of cases, however, this division 
holds good. It is a perfectly logical one, because it is in the second half 
of pregnancy that the three positive signs of pregnancy appear. The 
term " half," however, need not be used in a strictly literal or mathe- 
matical sense. The division is approximate rather than exact. In many 
cases pregnancy will be somewhat more than half over before any one 
of the three positive signs mentioned above can be demonstrated. 

For purposes of diagnosis then, we divide pregnancy into two periods. 

27 



28 PREGNANCY, LABOR AND THE PUERPERIUM 

In considering the diagnostic evidences of each we divide these evidences 
into two classes — symptoms and signs. 

This ancient classification is convenient and practical. The symptoms 
of pregnancy are, in the main, subjective, or at least they are first noted 
by the patient. While highly suggestive and valuable they are not abso- 
lutely infallible since they may possibly have causes other than pregnancy. 
Moreover, they may be simulated or denied. IMorning sickness and 
cessation of the menses are examples of the '' symptoms " of early 
pregnancy and '' c[uickening " is a symptom that usually ushers in the 
second half of pregnancy. 

" Signs," on the other hand, are amenable to inspection, palpation and 
auscultation. They cannot be simulated, and it is useless to deny them. 
Among the signs of pregnancy are found those which in the early months 
of pregnancy are almost positive, zns., the local changes in the uterus, 
and those which in the second stage are absolutely positive, e.g., the recog- 
nition by a competent examiner of the fetal heart sounds, the fetal move- 
ments, and the different parts of the foetus. These signs can only be 
caused by the presence of the foetus itself. It is only during the latter 
months of pregnancy that they are sufficiently well developed for positive 
recognition. 

Even in the first period the physical signs are, in doubtful cases, more 
valuable than any mere symptoms can possibly be. 

These facts clearly shozv that one cannot learn hozv to diagnose preg- 
nancy by reading hooks, or by listening to lectures, hut only by actual 
clinical practice. 

Let us begin then with the first period, the period of doubt. What are 
the early symptoms of this period? In other words, what are the earliest 
symptoms of pregnancy? 

Cessation of Menstruation. — ^First, and most important of all, is the 
cessation of the menses. Alost women indeed make their own diagnosis 
from this symptom, and as a rule, correctly. There are, however, certain 
exceptions which should be firmly fixed in the mind of the beginner. 
Lactation is the most common cause of absence of menstruation during 
the child-bearing period. It is true that women do not ordinarily conceive 
during lactation, but there are many exceptions to this rule. 

It is the observation of every physician that nervousness and appre- 
hension, the result of an undesired, or possibly an illegitimate pregnancy, 
may delay the advent of the menstrual period. It may be absent for long 
periods in conditions of profound anaemia, especially in young women and 
girls, or after severe hemorrhage, e.g., in cases of abortion or placenta 
prsevia. Again conception may occur in young girls before the establish- 
ment of the menstrual flow, and it has been known to occur in women 
of middle age after menstruation had apparently ceased. 

Then, too, there may be one or more periods or pseudo periods after 
conception. A single menstruation after conception lasting but a day or 



CLINICAL PHENOMENA OF PREGNANCY 29 

two, the discharge being hght in color and small in amount, is not at all 
luicommon, and may lead to a mistake of four weeks in estimating the 
date of labor. The attendant should always recall this and not forget to 
question his patient upon this point. 

\\> hear sometimes of patients who are said to menstruate regularly 
during pregnancy. IMost of these cases are apocryphal, although men- 
struation is of course mechanically possible before the fusion of the 
decidua and the decidua reflexa, which occurs at about the fifth month. 
Every case of supposed menstruation during pregnancy should be investi- 
gated in order that the source of the hemorrhage may be determined. It 
may indicate a decidual endometritis, or a molar pregnancy, and it may 
forebode an abortion. In the latter months it may indicate placenta 
previa. 

The Nausea of Pregnancy. — ^Next in importance as a symptom of 
early pregnancy is the nausea of pregnancy, or " morning sickness," to use 
an expressive term that has become imbedded in the popular vocabulary, 
and in the literature of the subject as well. While not a necessary part 
of normal pregnancy, it is nevertheless so common, especially in primiparse, 
that in its milder forms it is hardly regarded as pathological. Few 
patients escape some traces of this unpleasant symptom. It is usually 
first noticed about the third or fourth week, but some women are nauseated 
almost from the moment of conception. It is usually most marked when 
the patient first assumes the erect posture in the morning, but it is not 
necessarily confined to the morning hours, and may occur at any time of 
the day. I recall one patient who was nauseated only in the evening. 
Sometimes there is only nausea, at other times both nausea and vomiting. 
More rarely there may be neither, but only complete loss of appetite, or 
perhaps a pronounced aversion for food. 

The vomiting of pregnancy in its milder forms is probably a neurosis 
and in its more severe a toxaemia. Some writers believe that toxaemia 
underlies even the mild cases. Vomiting occurring in the latter months 
of pregnancy may forebode eclampsia, and should remind us not to omit 
urinalysis. 

JMorning sickness, when occurring in women who have been exposed to 
the possibility of conception, and who have been free from indigestion or 
nausea before pregnancy, is a corroborative symptom of great value. It 
is also, as DeLee remarks, an evidence of the life of the child, since we 
know that vomiting usually ceases with the child's death. 

It is not an absolutely reliable symptom, however. In the first place, 
it may be simulated, or its existence falsely asserted. If a patient states 
that she is nauseated, or vomits in the morning, there is no way of abso- 
lutely disproving her statement. Again it may be the result of suggestion 
as in pseudocyesis or spurious pregnancy. Hirst notes that the husband 
is sometimes affected and two or three instances of this peculiar 
phenomenon have fallen under my observation. 



30 PREGNANCY, LABOR AND THE PUERPERIUM 

Somewhat akin to morning sickness, though much less common, are 
an excessive secretion of sahva, and the so-called longings for unusual 
and perhaps previously disliked articles of diet. 

Frequent Urination. — This symptom, although given little or no 
attention by many writers, is in my experience one of the most common 
evidences of early pregnancy, and one with reference to which I never 
fail to question the patient. The existence of this symptom is not usually 
falsely asserted or denied since most patients, apparently, are not familiar 
with the fact that it is an evidence of pregnancy. 

What is the cause of frequent urination in early pregnancy? It is 
usually attributed to pressure upon the bladder by the growing uterus, 
but it is often observed very early before enlargement can have taken 
place. According to DeLee it is not due to pressure from the pregnant 
uterus because the specific gravity of the latter is only about the same as 
that of the intestines, but is due to stretching of the base of the bladder 
by the backward displacement of the cervix which attends the usual 
anteversion of the pregnant uterus. 

Increased Vaginal Secretion. — This is often noticed by the patient, 
who is not likely to mention it, however, unless asked. It is the natural 
consequence of the congestion of the entire birth canal and pelvic contents, 
already mentioned, and, occurring in patients not previously subject to 
leucorrhoea, has considerable diagnostic significance. 

Symptoms Referable to the Breasts. — We will speak presently of 
certain changes in the breasts and nipples that are characteristic of 
pregnancy. These are apparent to the eye and belong among the signs 
of the condition. Before these signs appear, however, certain patients 
experience peculiar sensations in the breasts, fugitive pains, a feeling of 
tension or '' prickling." These are of some value as corroborative evi- 
dence ; indeed, in multiparse they are of more value than the changes 
apparent to the eye, since the latter may be the result of a previous 
pregnancy. 

Mental and Nervous Changes. — As noted in the foregoing chapter, 
changes in disposition and mental outlook are common in early pregnancy. 
They are of considerable corroborative value to those who know the 
patient well, and especially to those who have been with her in previous 
pregnancies ; for example, to her family and her family physician. 

These changes commonly take the form of irritability, despondency, 
and nervous apprehension. They are a part of the general depression 
that goes with the early months of pregnancy, and fortunately does not 
usually outlast them. 

]Much more rarely the patient manifests a cheerfulness foreign to her 
usual disposition. There are some women who feel better both mentally 
and physically during pregnancy than at any other time. 

The reader will notice at once, that for the most important of the 
evidences of pregnancy thus far considered, we are obliged to depend 



CLIXICAL PHENOMENA OF PREGNANCY 



31 



upon the statements of the patient. When these statements can be rehed 
upon they are of great value, and there is usually little difficulty in making 
a diagnosis. As a rule it has already been made by the patient herself, 
and made correctly. ^Moreover, in these cases no immediate diagnosis is 
necessary, and it is always possible to wait a few weeks for additional 
evidence. 

But let us suppose that definite information is desired. Perhaps we 
do not know the patient, or, if we do, we may have reason to distrust 
her statements. 



. 1 






'^^f 

t 



f/ 



r ^f 



Fig. 20.- 



-Sensation imparted to the palpating finger by (a) the non-pregnant uterus, {b) the pregnant 

uterus. 



Under these circumstances there is but one way to obtain reliable infor- 
mation, and that is to search for those physical signs of pregnancy that 
cannot be simulated. These are, in the early months, the changes in the 
size, shape, position and consistency of the uterus. These changes are 
highly characteristic, and the experienced observer is seldom deceived. 

It is self-evident that before one can recognize the changes of early 
pregnancy, he must be familiar with the size, shape, etc., of the normal 
uterus in the non-pregnant condition. It is absolutely necessary tliat he 



32 



PREGNANCY, LABOR AND THE PUERPERIUM 



be familiar with the methods and results of the ordinary bimanual 
gyncTCological examination. If he does not know the normal uterus he 
will seek in vain for those deviations from the normal that mark the early 
months of pregnancy. 

In the next place he should become familiar by actual exploration with 
the changes that do occur in early pregnancy. This knowledge can only 
be gained by practice. He should, therefore, from the beginning of his 
career, never neglect the opportunity of examining women in the early 
months of pregnancy. In this way the persevering and intelligent young 
physician will soon master the problem. 



X 




Fig. 21. — Hegar's sign. 



Changes in the Uterus. — What then are the changes to be noted? 
In the first place the uterus is larger than in the non-pregnant condition, 
and since its normal anteflexion is increased, the finger carried into the 
anterior cul de sac notes this enlargement at once. What strikes the 
novice making his first examination is that instead of having to search 
for the body of the uterus, he cannot help feeling it At six weeks the 
enlargement is quite noticeable, and the practiced hand can detect it two 
or three weeks earlier. 

At the same time the examiner notes a very remarkable change in the 



CLINICAL PHENOMENA OF PREGNANCY 



33 



consistency of the uterus ; a change more easily recognized than described. 
The body of the uterus instead of being smooth, firm, and hard, as in the 
virgin or non-pregnant state, has a doughy feel. One detects slight irregu- 
larities here and there. The uterine body is as a whole fairly symmetrical, 
although careful examination will sometimes show an anteroposterior 
thickening, greater on one side than on the other. This is known as the 
sign of Braun von Fernwald, and is due to the presence of the ovum in one 
upper angle of the uterus. Later the growing ovum completely fills the 
uterine cavity, and the irregularity disappears. 

The cervix is softer than in the non-pregnant condition, a sign of some 
value but far less significant than the signs referable to the body of the 




Fig. 22. — Hegar's sign. Negative, uterine hypertrophy being due to a fibroma. 

Uterus. A writer, given to homely but effective comparisons, once said 
that in the non-pregnant condition the cervix feels like the tip of the nose, 
while in pregnancy it feels like the lips. A more accurate comparison 
is that of Fabre, who says that the cervix in pregnancy feels like a hard 
body covered with velvet. The thoughtful examiner will notice that the 
softening of the cervix is more superficial than that of the uterus. 

The cervix is much shortened, or, at least, it appears to be shortened. 
This is due to the distention and consequent globular shape of the lower 
uterine segment. The examining finger passed into the cul dc sac, instead 
of running along a gradually increasing curve as in the non-pregnant 
condition, comes squarely up against the lower segment of the uterus. 
This is one of the most important and most easily recognized signs of early 
pregnancy. While it does not easily lend itself to written description, it is 
made perfectly plain in Fig. 20. 
3 



34 PREGXAXCY, LABOR AND THE PUERPERIUM 

Hegar's Sign.— But it is the lower uterine segment that gives us what 
is perhaps the most significant and positive sign of early pregnancy. The 
lower uterine segment becomes much softer than the cervix. So soft, 
indeed, does it become that in its empty state ( for it has not as yet become 
encroached upon by the growing ovum), it can be compressed almost to 
the thinness of paper. This gives us what is known the world over as 
Hegar's sign, to which it is well worth our while to devote careful attention. 

Figs. 21 and 22 show how to elicit Hegar's sign. The two fingers 
in the anterior cul de sac are made to meet the fingers of the external hand. 




Fig. 23. — McDonald's sign. 

The softened lower uterine segment ofTers no resistance, and the fundus 
feels like a tumor completely separated from the cervix, or attached to 
the latter by a pedicle. Indeed, this mistake has been made many times by 
those unfamiliar with obstetrical manipulations, the cervix being taken for 
the body of the uterus, and the latter for a new growth. Hegar's sign is 
available at about the tenth week, sometimes a little earlier. That there 
are changes in the lower uterine segment, however, that can be recognized 
even before this time, cannot be doubted in view of the evidence of various 
skilled observers. 



CLIXICAL PHENO^IENA OF PREGNANCY 



35 



McDonald's Sign. — ]\IcDonald claims that during the first month 
of pregnancy it is possible to Ilex the cervix upon the body of the uterus 
in such a way as to bring the two into contact. This of course is another 
way of demonstrating the softening of the lower uterine segment. Accord- 
ing to ]\IcDonald this increased flexibility of the cervix can be made out 
before softening is appreciable to the touch (Fig. 23). 

Ladinski's Sign. — Ladinski's sign is one of the most valuable evidences 




Fig. 24. — Ladinski's sign. 

of early pregnancy, and can often be demonstrated before either 
IVIcDonald's or Hegar's signs are available. It depends upon the presence 
in the anterior wall of the uterus just above the cervical junction of a 
soft, elastic, fluctuating area. According to Ladinski this can frequently 
be made out as early as the fifth week, when it is the size of a finger-tip, 
and always in the sixth week. This area increases in size during the 
first three months until it is gradually lost in the general and complete 
softening of the lower uterine segment. In marked retroflexion it is 
found on the posterior uterine wall but does not appear until about a 
week later (Fig. 24). 

Ladinski also claims that the presence of this sign serves to differ- 
entiate normal from extra-uterine pregnancy, and also that the elastic 



36 PREGNANCY, LABOR AND THE PUERPERIUM 

area becomes soft, doughy and incompressible with the death of the foetus, 
thus permitting one to distinguish between threatened and inevitable 
abortion. 

The sign is not difficult to elicit. It is only necessary to fix the body 
of the uterus by external pressure, meanwhile palpating its anterior surface 
from cervix to fundus. 

Failure to elicit Hegar's sign as well as the other physical signs of 
early pregnancy is due, not so much to any intrinsic difficulties in the 
subject, as to lack of clinical experience on the part of the examiner, and 
to improper technic in the conduct of the examination. Of the first I 
have already spoken. A few words with reference to the second may 
not be out of place. 

Whenever practicable the examination should be made upon a table, 
not upon a bed. The patient should be in the dorsal position with the 
knees moderately flexed and the head and shoulders slightly raised. In 
this way the greatest relaxation is secured. 

/Two fingers of one hand are carried into the anterior cul de sac, 
noting meanwhile the condition of the cervix. They are introduced slowly 
and carefully. Rough and hasty manipulations make satisfactory exam- 
ination impossible. The patient should be assured that the examination 
will be attended by little or no pain, and encouraged to relax her abdominal 
muscles and to breathe with her mouth open and with prolonged expira- 
tions. The external hand applied to the abdomen should be depressed 
very slowly, in order not to frighten the patient and excite involuntary 
resistance. It should not be applied too low, i.e., too near the symphysis, 
or it will not be carried above and behind the uterus, as is absolutely 
necessary. Should the examiner find the anterior cul de sac empty, he 
should not hastily conclude that pregnancy is out of the question, but 
remember that in the early months the uterus is occasionally, if rarely, 
retroflexed. 

Now and then one meets a patient with an abdominal wall so thick 
as to make satisfactory bimanual examination impossible. In such cases 
Hegar's sign may sometimes be obtained by passing the thumb into the 
vagina and the finger into the rectum. As a rule, however, the employment 
of pain-producing measures, or those requiring anaesthesia, is to be 
avoided, not only out of regard for motives of delicacy and humanity, but 
also because of the danger of abortion. They are to be used only in those 
cases in which an imxmediate diagnosis is a matter of vital importance. 

To sum up, the most valuable, and the only really positive signs of 
pregnancy in the early months are those obtained by bimanual exploration. 
When the practiced hand finds the changes described above, pregnancy is 
almost proven. If, at an examination made two or three months later, 
the same characteristic changes are verified, and the uterus has in the 
meantime enlarged symmetrically, pregnancy can hardly be doubted. But 
the required knoivledge and experience are presupposed. Where these 



CLINICAL PHENOMENA OE PREGNANCY 37 

are lacking the attendant should beware of making anything more than 
a provisional diagnosis. If in doubt, he should frankly say so, stating 
that more time will be required for a positive diagnosis. Eor this no 
one can blame him; but if he makes a positive diagnosis which proves 
incorrect the result wall be embarrassing. 

Let me repeat that the diagnosis of pregnancy, and especially of the 
first half of pregnancy, cannot be learned from books. As well attempt 
to learn watchmaking from books without ever seeing or handling the 
inside of a watch. The ambitious student should make up his mind 
at the start that proficiency in this work can be gained only by actual 
practice, using the method outlined above. There is no other zvay. 

Inspection. — During the early months little is to be gained by inspec- 
tion. The abdomen is still flat, perhaps even more so than usual. The 
rhyme of ^Madame Lachapelle, Ventre plat, enfant il y a, has become an 
obstetrical classic. But such negative information is of little value. 
Toward the end of the fourth month, beginning enlargement of the 
abdomen can be made out, but before this there is usually nothing to be 
seen, though the patient may complain that her clothes are a little too tight. 

A\^ith the advance of pregnancy, the fundus rises in the abdominal 
cavity, and the navel, at first flat, becomes depressed and later protrudes. 
The ascent of the uterus, and the height which it attains at different periods 
of pregnancy, are considered elsewhere, and we shall see later how it finally 
reaches the neighborhood of the ensiform cartilage only to descend three 
weeks before labor. 

Swelling of the breasts and prominence of the superficial veins may 
attract attention. The primary areola and the tubercles of Montgomery 
may be quite noticeable at the sixth week. All these changes, however, 
may be absent. The secondary areola and the pigmentation of the linea 
alba do not come until later. 

I believe, though I have not seen it in print, that there is such a thing 
as the facies of early pregnancy ; not always present, it is true, but present 
in a considerable number of cases, a certain pallid and haggard appear- 
ance, and a facial expression, difficult to describe, but sufficiently obvious 
to the experienced observer. Dark lines under the eyes are common. 

Chadwick's Sign. — ^Another sign which usually makes its appearance 
about the third month, sometimes earlier, and continues throughout preg- 
nancy, becoming more marked toward the end, is the deep violet color of 
the visible mucous membrane about the vulva and vagina, and especially 
that of the vestibule and anterior vaginal wall. It Is the result of the 
congestion of the entire birth canal that accompanies pregnancy and Is 
made more marked by anything that Increases the congestion, e.c/., the 
pressure of the head In cases of pelvic contraction, or the presence of a 
large tumor, or the general congestion of mucous membranes that charac- 
terizes certain forms of cardiac disease. Its value Is only corroborative. 

Chadwick, of Boston, was the first American to describe this phenome- 



38 PREGNANCY, LABOR AND THE PUERPERIUM 

non in detail, and since the publication of his paper in 1886, it has been 
known as Chadwick's sign. 

During the fourth and fifth months the uterus continues to increase 
steadily in size, and this helps to confirm the diagnosis which has by this 
time usually been made. This steady and rapid growth of the uterus is 
in itself a very valuable sign of pregnancy. No morbid growth increases 
in size as fast as does the pregnant uterus. 

This period of pregnancy is marked by the appearance, or possible 
appearance, of three important signs relating to the foetus. For the most 
part, however, they are not sufficiently marked to be of much service until 
the patient is well along in the second period. I refer here to ballottement, 
quickening, and the fetal heart. 

Ballottement. — This is one of the classical signs of pregnancy. It can 
be made out toward the end of the fourth month, but is best recognized 
during the fifth and sixth months. It is obtained as follows : One hand 
is placed over the fundus and pressed firmly downward so as to come in 
contact with the foetus. Two fingers of the other hand are then passed 
well up into the vagina and made to touch the lower fetal pole, usually 
the head. This is pushed quickly upward by a sort of tapping movement. 
The hand at the fundus feels the impact of the ascending foetus, and the 
fingers in the vagina feel its return. After the sixth month, the foetus 
does not float in the now relatively smaU amount of amniotic fluid, and this 
sign is no longer available. In cases of hydramnion, however, it can be 
practised up to the very beginning of labor. 

As a rule, by the time that ballottement can be satisfactorily practised 
the other evidences of pregnancy are sufficiently definite. Nevertheless, 
this sign is highly characteristic and in doubtful cases of considerable 
value. It is particularly useful in patients who are so stout that a satis- 
factory bimanual examination is difficult or impossible. Other con- 
ditions said to simulate it are stone in the bladder and an anteverted 
uterus, or a pediculated tumor, swimming in ascitic fluid. The latter is 
the only one that seems within the range of probability. 

A sort of external ballottement is sometimes practised, the patient lying 
upon her side, and the examiner using his hands as in trying to recognize 
the impulse of ascitic fluid. 

Quickening. — Toward the end of the first period a new evidence of 
pregnancy is observed, one which is always of great interest to the patient, 
and is usually eagerly welcomed. Ancient custom has given it the sug- 
gestive title of quickening. By this term is meant the sensation caused by 
the contact of the fetal parts with the endometrium during active move- 
ments of the foetus. It is usually observed earlier in multiparae than in 
primipar^e. It is described by the patient as a faint, wavy or fluttering 
sensation, which she appreciates but finds it hard to describe. With the 
advance of pregnancy the movements become more pronounced. Like the 



CLINICAL PHENOMENA OF PREGNANCY 39 

contractions of pregnancy they are more noticeable at night when there 
is less to distract nervous attention than in the daytime. 

In some cases the fetal movements are quite painful to the mother. 
This has been attributed to undue sensitiveness of the uterine wall, the 
result of an old endometritis, and it has been remarked that in such cases 
the uterus is tender on pressure. Sometimes, even in advanced pregnancy, 
fetal movements may be absent for days at a time, though the life of the 
foetus is attested by the fetal heart sounds. 

Standing by itself the sensation of quickening, as described by the 
patient, is not of great value. Highly nervous patients may imagine it 
and of course it may be simulated. ^lovements of gas in the intestine 
and spasmodic contractions of the abdominal muscles have been mistaken 
for fetal movements. 

The perception of fetal movements by the examiner, however, is, as 
we shall presently see, of the greatest possible importance. Rarely fetal 
heart movements may be felt externally, especially in face presentation 
in which the fetal thorax is crowded against the mother's abdomen. 

The funic souffle is a high-pitched blowing or whistling sound, synchro- 
nous with the fetal heart and often intermittent, i.e., it will be heard at one 
examination and absent at another. It is probably produced by some 
temporary obstruction in the umbilical arteries since it is occasionally 
produced by the pressure of the stethoscope. This is a valuable sign when 
present but it is often absent. 

The uterine souffle is a blowing sound of lower pitch as of fluid rushing 
through a large tube, heard synchronous with the maternal pulse and 
caused by the current of blood in the uterine arteries. It was formerly 
but incorrectly called the placental souffle. While suggestive, it is not of 
any great diagnostic value, since it only indicates enlargement of the 
uterine arteries and such enlargement occurs in other conditions, e.g., in 
fibroid or ovarian tumors. It is best heard upon the left side since, owing 
to the right obliquity of the uterus already mentioned, the vessels are 
here nearer the surface. According to some writers it may indicate the 
position of the foetus in ectopic gestation. 

The Fetal Heart. — The recognition of the fetal heart sounds is 
positive evidence of pregnancy, but while it is occasionally possible to 
hear them during the first four and one-half months, this sign is not 
usually available until later. Moreover, these sounds are by no means as 
distinct in the seventh and eighth months, as in the ninth and tenth. This 
sign then belongs to the second period of pregnancy. 

It will be convenient to consider here three classes of symptoms, which, 
beginning early in pregnancy, continue during both the first and second 
periods, indeed up to the beginning of labor, vie, the changes in the 
shape and size of the abdomen, the changes in the breasts, and the painless 
contractions of pregnancy. 

Changes in the Abdominal Tumor. — Abdominal distention is not 



40 PREGXAXCY, LABOR AND THE PUERPERIUM 

apparent to the eye until the end of the fourth month. At five months 
the fundus is about half-way between the symphysis and the umbilicus. 
From this time the fundus gradually rises until about three weeks before 
term, when it reaches its highest point, the epigastrium, and then sinks to 
a lower position as the head becomes engaged in the pelvic cavity. At 
six months the fundus has reached the navel, which has now ceased to be 



/ 



"N- 



^ \ 

Centimetres Month. 



%^ 



PU|S 



Fig. 25. — Height of fundus at different periods of prfegnancy. 

a depression and later protrudes. From this point on it rises at the rate 
of about 4 cm. per month until it nearly reaches the xiphoid cartilage, 
then sinks as above. In multiparse the descent of the fundus does not begin 
until a week or ten days before term and is much less marked. 

The landmarks usuallv given, however, are often unreliable. The 



CLINICAL PHENOMENA OF PREGNANCY 



41 



height of the iimbiHcus is variable, and, in " long-waisted " women, the 
xiphoid cartilage and the false ribs are much higher than in others. Hence 
the distance of the fundus above the pubis is a better criterion. Fig. 25 
shows the distance of the fundus from the symphysis at different periods 




Fig. 26. — Measuring height of fundus at term. 



of pregnancy, and Fig. 26 the method of measuring the height of the 

fundus at term. The advance of the fundus has been estimated at 4 cm. 

a month, and will be found to correspond pretty closely to this estimate. 

Unusual height of the fundus may indicate some condition which 



42 PREGNANCY, LABOR AND THE PUERPERIUM 

prevents the head from entering the pelvic brim, e.g., contraction of the 
pelvis, or unusual size of the child. In twin pregnancy it may be markedly 
increased, and the same is true of hydramnion. 

Changes in the Breasts. — Enlargement of the breasts may be noted as 
early as the second month. This enlargement is accompanied by the 
appearance of prominent superficial veins beneath the skin. Shortly 
after this a pigmented area appears about the nipple, the primary areola, 
and a thin, whitish, watery fluid can be expressed. Toward the middle 
of pregnancy this becomes yellowish, colostrum. It is not until about 
the sixth month that the secondary areola appears. The glands of 
Montgomery, enlarged sebaceous glands, white in color, are seen scattered 
through the primary and sometimes through the secondary areola, and 
presenting a striking contrast to the darkened surface about them. The 
nipple itself becomes darker and more readily erectile. Pigmentation is 
much more marked in patients of the brunette type. Under the skin one 
feels readily the hypertrophy of the gland proper, hard, rough, nodular 
and fissured. In blondes the nipple and areola become a deeper, or reddish, 
pink. Thus we see that in either case there is a deepening of the original 
color (Figs. 27, 28, 29 and 30). 

The breast changes are of considerable diagnostic value in primiparse, 
especially the secretion of a milky fluid. They are of less value in multi- 
parse, who often have a little fluid in the breast, especially if they have 
recently been nursing a child. Then, too, the pigment of a former 
pregnancy may remain. 

Swelling of the breasts may occur during menstruation, and it may 
accompany extra-uterine pregnancy, spurious pregnancy, and pelvic or 
abdominal tumors. 

In cases of great distention the breasts, as well as the abdomen, may 
become the seat of the linece alhicantes already mentioned. 

The Intermittent Contractions of Pregnancy. — From about the 
tenth week of pregnancy, the palpating hand recognizes a hardening of 
the uterus recurring at irregular intervals. This is caused by what are 
known as the intermittent contractions of pregnancy, or the painless con- 
tractions of pregnancy, or, as they are often called, after their discoverer, 
the intermittent contractions of Braxton Hicks. They may be appreciated 
either by external or internal examination. Of course the external method 
is not applicable until the fundus has risen well above the symphysis. 

As a rule the contractions recur at intervals of five or ten minutes, 
but they may be hours apart. They have been observed not only in preg- 
nancy, but also in fibroids and in h^matometra. During the latter part 
of pregnancy these contractions become more frequent and more marked, 
and are often noticed by the patient herself, who remarks the hardening of 
the abdominal surface. They are not always painless but as labor 
approaches may become quite painful, especially in the early hours of the 
morning; so painful, indeed, that the patient and those about her may 





Fig. 27. — Virgin blonde. 



1 



Fig. 28. — Pregnant blonde. 




*^-: 




Fig. 29. — Virgin brunette. 



Fig. 30. — Pregnant brunette. 



CLIXICAL PHENOMENA OF PREGNANCY 43 

think that labor has begun, only to find that the pains wear away as the 
day advances. 

The contractions of pregnancy are of little diagnostic value in early 
pregnancy, since they may be absent for hours at a time, and, even if 
present, may be due to other causes. In the latter months they are, it is 
true, very characteristic, but by that time the other signs of pregnancy are 
usually amply sufficient. Strong, but painless, contractions occurring 
weeks or even months before term, may indicate the death of the foetus. 

I regard these contractions as the natural response of a hollow mus- 
cular organ to the reflex influence of distention. In my opinion they 
prepare the way for labor, and often dilate the cervix to a considerable 
extent, though the latter is denied by some writers. I have observed 
tension of the " bag of waters " during a painless contraction, long before 
the beginning of labor. 

The Period of Certainty. — The latter half, or, to be more exact, the 
last three and one-half to four and one-half months, of pregnancy, are 
attended by the development of the three positive and unmistakable signs. 
Except perhaps in an occasional case of uterine tumor, or of great obesity, 
one or more of these signs can always be distinguished by the experienced 
examiner. 

AVhat are these signs ? 

1. The fetal heart sounds. 

2. The recognition, by the examiner, of the fetal movements. 

3. The mapping out of the different parts of the foetus. 

The first and third of these will be considered in the chapter on the 
antepartum examination, as they are indispensable parts of the physical 
diagnosis of pregnancy. We will consider here only the second. 

As already noted, the supposed perception by the patient of fetal 
movements is only suggestive, though it is of course highly valuable as 
corroborative evidence. I recall a case of spurious pregnancy in which 
the patient claimed to feel strong fetal movements. On examination I 
found that she did have powerful movements, far too powerful in fact to 
be produced by any foetus ; contractions of the abdominal muscles, that 
shook her entire body. 

In seeking to feel the movements of the foetus, the hand should be 
allowed to rest quietly upon the abdominal surface, not seeking to excite 
fetal movements, but waiting for them. They are most likely to be felt 
on the side opposite the dorsum as they are most often produced by the 
lower extremities. When thus produced, they are felt as light taps, quite 
unlike anything else that can be felt by abdominal palpation. Sometimes 
the whole body moves ; the deplacement en masse of the French writers. 
In this case the heaving, twisting motion of the fetal body, clearly felt and 
appreciated through the abdominal wall, communicates to the examining 
hand a sensation at once vivid and indescribable ; utterly unlike anything 
else in the whole realm of physical diagnosis. 



44 PREGNANCY, LABOR AND THE PUERPERIUM 

The reader cannot fail to note that in the second half of pregnancy as 
in the first, in the positive signs as in the probable, it is practice and 
expertness in the physical diagnosis of pregnancy that counts for most. 
jMistakes are due to lack of proper training. Such mistakes are often 
made by men justly eminent in other departments of medicine. They 
are seldom made by a young man who has served six months in a maternity 
hospital. When the schools have learned to pay as much attention to the 
diagnosis of pregnancy as they now do to the diagnosis of pleurisy such 
mistakes will be rare indeed. 

Duration of Pregnancy. — ^We have already seen that there is no 
method of determining the exact date of conception. Hence, even if the 
duration of pregnancy were always an exact quantity, we could not predict 
with absolute accuracy the date of labor. 

But the duration of pregnancy is not the same in every case. This 
fact finds illustration in every-day practice. Many tell us, that if preg- 
nancy is apparently prolonged two or three weeks, conception must have 
occurred not shortly after the last menstrual period, but just before 
what would have been the following one. This, however, is disproved by 
the fact, well known to every observant physician, that in these cases the 
foetus is unusually large and well developed. Of course there are excep- 
tions, since we know that conception may occur at any time, but this is 
the rule. 

Ahlfeld's tables show a variation of ninety-nine days, and even 
when fourteen per cent, in which premature labor was surmised and six 
per cent, in which pregnancy was thought to be prolonged beyond the 
forty-first week are excluded, there remains a variation of three weeks. 
This seerns to show, that, as I have maintained elsewhere, the duration 
of pregnancy is approximate, not fixed, and that there is no special day 
on which labor begins. It also corresponds with the observation of all 
physicians that mistakes of a week or two in estimating the duration of a 
given pregnancy, are the rule rather than the exception. This brings 
us to a question of practical interest. 

Hovv TO Predict the Date of Labor. — Fortunately the problem is 
not as difficult as it might seem from the above. Age-long experience has 
shown that labor occurs approximately 280 days from the first day ot 
the last menstruation, and that conception usually occurs within the first 
few days following menstruation. 

There are several rules for computing the date of labor all based upon 
these facts. The following is the one that I have been in the habit of 
usmg. Add five days to the last day of the last menstruation, and count 
back three (calendar) months. Thus, the last day of the last men- 
struation was April 3rd. Adding five days, and counting back three 
months, we have January 8th, the day of the expected confinement. Many 
compute from the first day of menstruation. This is a less reliable method, 



CLINICAL PHENOMENA OF PREGNANCY 45 

since the duration of the menstrual period varies within wide Hmits. 
Some women menstruate for two or three days, others for a week. 

AMiatever method is used, it is always well to inform the patient that 
there is no way of securing exact results and that mistakes of a week 
or two are common. 

If one would be precise, he must make allowance for leap year, and for 
months that contain less than thirty-one days. Such trouble is hardly 
worth while, however, in a computation the results of which are at best 
only approximate. 

Although the menstrual history affords by far the best basis for esti- 
mating the date of labor, the examiner should never forget to inquire 
as to the character of the last menstruation. This is especially important 
in cases in which the attendant circumstances lead him to believe that she 
is further advanced in pregnancy than she supposes or than she represents 
herself to be. As noted elsewhere, it is very common for a single pseudo 
period to occur after conception. This period usually lasts but a day 
or two, the discharge being slight in amount and light in color. 

How TO Estimate the Period of Pregnancy When the Men- 
strual History is Negative. — In some cases the date of the last men- 
struation is not known. Perhaps conception occurred in girlhood before 
the appearance of the menses, or during lactation when menstruation is, 
as a rule, in abeyance, or as happens now and then, in middle life, after 
menstruation had apparently ceased. In cases of this kind the estimation 
of the period to which pregnancy has advanced may be a matter of the 
greatest importance, e.g., when the induction of labor is under 
consideration. 

The symptom upon w^hich the laity are accustomed to lay most stress 
is quickening. Little reliance can be placed upon this symptom. As 
already noted, it is usually experienced at about four and one-half months 
in multiparse, a little earlier than in primiparse. These figures are very 
variable, however, and the perception of fetal movements may be imagined 
or simulated. 

On the whole, the most valuable evidence is to be found in the height 
of the fundus. The examiner should recall, however, that this height 
is subject to certain modifications. For example, in pelvic contraction 
the head may remain far above the brim and the fundus therefore be 
relatively very high, while during the " lightening " which accompanies 
the latter weeks of pregnancy, it sinks to the position occupied during 
the month before. 

He should remember that it is better to determine the height of the 
fundus by the tape measure, than to estimate it by its relation to the 
umbilicus. 

A method of determination introduced by Ahlfeld is based upon the 
length of the child. This is taken with the pelvimeter, one point of V\^hich 
is placed upon the head in the anterior cul dc sac, and the other upon 



46 



PREGNANCY, LABOR AND THE PUERPERIUM 



the breech. The procedure is made clear by the accompanying illustration 

(Fig. 31). 

The length of the child is perhaps the most reliable criterion of its 
period of development. According to Ahlfeld the length of the foetus, 
as taken in the manner just indicated, represents one-half its length when 
the body is extended, as it would be in measuring the foetus after delivery. 
In other words, one-half its real length. A mature foetus averages fifty 
centimetres in length. If the measurement in titer is twenty-five 
centimetres it is probable that the foetus is at or near term. 

The descent of the fundus, which usually occurs about three weeks 
before delivery, the so-called " lightening " of the laity, when observed 




Fig. 31. — Ahlf eld's method of determining the period of development by measuring the length of child. 



by a watchful and intelligent patient, is a pretty good indication that 
labor cannot be far away. 

When in the case of a primipara who has experienced this descent of 
the fundus the head is found well down in the cavity of the pelvis, the 
cervix admits the finger, and the canal is apparently very short, or the 
anterior lip is obliterated, one is safe in saying that the end of pregnancy 
is near. Frequent urination, and some difficulty in walking, are symptoms 
often obser^-ed at this time. 

Hov^ to Determine Whether the Foetus is Alive. — The maternal 
instinct always responds gratefully to any interest shown in the welfare of 
the child, whether in pregnancy, labor, or the puerperium. ]\Ioreover, if 
the child is dead, it is better that the physician should be in a position 



CLIXICAL PHENOMENA OF PREGNANCY 47 

to inform the parents of this fact, than that they should be surprised by 
the unwelcome news at a later date. 

Failure to hear the fetal heart sounds or to feel fetal movements is 
suggestive, but is never in itself positive evidence of the death of the 
foetus. Cessation of fetal movements and fetal heart sounds that have 
once been felt and heard is, however, highly important. Other signs are 
diminution in the size of the uterus, which feels harder than before, 
and a feeling of weight in the abdomen. The fundus is not as high as 
previotisly, or at least it ceases to rise in the abdomen, as shown by measure- 
ments taken at intervals. Upon palpation a crackling sound of sinister 
omen is heard, the result of the movement upon each other of the bones 
of the cranium. The parchment-like feel and the free movement of the 
bones upon each other may be recognized by internal examination, if the 
head is within reach. A brownish-red discharge may occur. This is 
valuable corroborative evidence, but, by itself, may indicate only a 
decidual endometritis. The breasts at first become congested and secrete 
milk as at the termination of normal pregnancy, but later diminish in size. 

]\Iost significant of all, in my experience, is the sudden increase in force 
of the painless contractions of pregnancy. For example, they may sud- 
denly become as marked in the sixth or seventh month of pregnancy as 
they usually are in the last week of pregnancy, or even more so. The 
outline of the uterus is very plain during the contractions, and the patient 
looks as though she were in true labor, but sufifers little or no pain. Nature 
seems to be trying to rid the organism of a guest no longer welcome. 

Certain constitutional symptoms may appear — slight chilliness, lassi- 
tude, depression. Vomiting, if it has existed, may cease, or toxaemic 
symptoms may abate. Nature has herself performed the cure. 

The history of the case may afford a valuable clue. For example, the 
foetus may have died at about the same period in one or more previous 
pregnancies. 

The Diagnosis of Multiparity. — Has the patient been pregnant before ? 
For medico-legal or other reasons an answer to this question may be 
desired. A previous pregnancy may be denied, or the patient may be 
unconscious or irresponsible. What are the physical signs of multiparity? 

The relaxed vaginal outlet resulting from an old perineal tear will 
hardly escape observation, but if present may be due to traumatism other 
than that of labor, e.g., rough or unskilled examination, or the removal 
of a fibrous polypus or other tumor per vaginam. Moreover, there are 
cases In which no trace of any tear can be discovered, and, very rarely, 
cases in which even the hymen Is Intact. Much more characteristic Is the 
slit-like orifice of the cervix, with a little notch at each end marking the 
slight bilateral tear that is the result of almost every labor. But even 
this Is not Invariably present. Now and then one meets a case In which 
the cervix shows no eflfect of labor whatever. 

In the case of a woman who has borne children, the breasts mav retain 



48 PREGXAXCY, LABOR AND THE PUERPERIU.AI 

the pigment of a previous pregnancy, and they may be more relaxed and 
pendant than in a primipara, but these signs are not absolutely reliable. 

The stricv upon abdomen, thighs, and breasts, white and glistening, 
the scars of a former pregnancy, contrasting vividly with the pinkish 
stricc of an existing pregnancy, certainly make a striking picture, but 
are absent in a certain number of cases, according to DeLee five to ten 
per cent. 

Familiar changes in the figure, e.g., a relaxed, prominent, or even 
pendulous abdomen, are common but by no means always present. 

The lapse of several years serves to make the recognition of a former 
pregnancy more difficult, but the most difficult cases of all are those in 
which pregnancy occurred in girlhood, perhaps at the age of fourteen or 
fifteen, and five or six years have elapsed. After a Csesarean section 
there may be no signs of pregnancy whatever, and the small incisions 
now made are hardly recognizable after a few years. 

It is plain then, that there wall always be a considerable proportion 
of cases in which absolute certainty is not attainable, and a few in which 
there is practically no evidence at all. 

Xevertheless, there is usually no great difficulty in the matter. \A'hile 
none of the signs mentioned above are infallible, if two or three of them 
are present, the presumption of previous pregnancy is very strong. Of 
all the evidences the relaxed vaginal outlet with the remains of a perineal 
tear, and the transverse slit in the cervix, are the most significant, ^^^hen 
with these we find the stricc of a previous pregnancy, the circumstantial 
evidence is sufficient for conviction. 

The Diagnosis of Sex. — The attempt to diagnose the sex of the foetus 
has hitherto been unsuccessful. There are, however, certain aids to a 
presumptive diagnosis that are of theoretical, rather than practical, interest. 

In the first place, it is said that the fetal heart beats faster in girls 
than in boys. 

In the second place, it is certain that the average size and weight 
of boys exceeds that of girls, though of course there are many exceptions 
to this rule. ^Moreover, it is difficult to estimate accuratelv the size of the 
child. 

Finally, certain writers teach that elderly primipar?e give birth to boys 
oftener than to girls. 

Taking all these factors together one may make a '' good guess " in a 
given case: but he is wise who reser^^es his decision until after delivery. 

The Serodiagnosis of Pregnancy. — As might have been expected, the 
new biologic theories have not been without effect upon the question of the 
diagnosis of pregnancy. Thus far, however, the results have been of 
theoretical rather than practical interest. Of the various tests of this 
kind the best known is that of Abderhalden and is based upon the fact that 
during pregnancy a foreign albumen gets into the blood through the 
medium of placental villi that are broken off and enter the general circu- 



CLINICAL PHENOMENA OF PREGNANCY 49 

lation and that, for the reduction of these elements, protective ferments 
are formed, the discovery of wliich constitutes a proof of pregnancy. 

All this appears easy on paper, but the laboratory technic is difficult and 
the results of diilerent experts conflicting. The characteristic reaction may. 
be found in other conditions and it appears, therefore, that for the present 
at least the test is of positive rather than negative value. For the sake 
of fairness, however, it must be admitted that Abderhalden and his 
followers claim that unsatisfactory results are due to defective technic. 

Thus it is plain that now as before the practitioner must be dependent 
for the most part at least upon the history and circumstances of the case 
and especially upon the results of physical examination. After all, the 
latter will seldom leave him in the lurch. The great essential is long and 
persevering practice of the methods we have already studied. 

The Differential Diagnosis of Pregnancy. — With the slight attention 
so often given to the physical diagnosis of pregnancy, it is not strange 
that the pregnant uterus has been confounded with tumors, and vice versa. 
Such mistakes are not as common as they were before the department of 
obstetrics became recognized as one of the most important departments 
of the medical curriculum. 

The methods of differentiating between pregnancy and fibroid, ovarian, 
or other tumors, will be discussed in connection with the pathology of 
pregnancy. 

Perhaps the most common difficulty with which the practitioner is 
confronted is the distinction between subinvolution and early pregnancy. 
In subinvolution the uterus is still considerably larger than normal, and 
still retains something of the softness and boggy consistence of pregnancy. 
To add to the difficulty, menstruation is often absent as a result of lactation 
anaemia, and the general condition and appearance of the patient resembles 
that of early pregnancy. 

In these cases, however, there will usually be the history of backache 
and profuse vaginal discharge, following the puerperium. Retroflexion is 
common, whereas in pregnancy it is exceptional. The uterus is often 
tender on pressure. The patient's sufferings are much aggravated. 

Chronic metritis has been mistaken for pregnancy, but this mistake 
should not be made by a competent examiner. In this condition the uterus 
is enlarged, but is harder than in pregnancy, and Hegar's sign and all the 
other signs based upon the softening of the lower uterine segment are 
absent. Moreover, there is a history of previous uterine disease, and an 
absence of the presumptive symptoms of pregnancy, cessation of men- 
struation, nausea, changes in the breasts, etc. 

In supravaginal hypertrophy of the uterus the unusual length and 
size of the cervix has sometimes caused it to be mistaken for the pregnant 
uterus. If the finger is carried high enough, however, the body of the 
uterus may be felt. 

In ascites some cardiac, hepatic, or renal cause will be found. The 
4 



50 



PREGNA.XCY, LABOR AND THE PUERPERIUM 



position of the fluid changes with the position of the patient. For 
example, if the patient stands or sits, the fluid settles to the lower part of 
the abdomen. INIoreover, vaginal examination is negative. 

To consider every condition that might possibly be mistaken for preg- 
nancy by the careless or incompetent would carry us too far. There is 
one condition, however, which every physician is likely to meet sooner or 
later, and which he should on no account forget to study. I refer to 
spurious pregnancy. 

Pseudocyesis or Spurious Pregnancy. — Recalling the part played by 
the maternal instinct in the life of woman, we need not wonder that in the 
study and in the diagnosis of pregnancy, the influence of suggestion must 
be taken into account. 




Fig. 32. — Hysterical tympanites. 

Spurious pregnancy, or phantom pregnancy, is not very uncommon, 
especially in patients who frequent the clinics of our large cities, where 
all races and types are represented. 

Naturally enough it is most common in those whose eager desire for 
maternity has not, and is not likely to be gratified. Thus it is most often 
encountered at the time of the menopause, or in the case of patients who 
have been long married but who have never conceived. 

Next to the element of desire comes the element of fear, and w^e 
occasionally find the symptoms of pregnancy imagined by those who 
have been exposed to the possibility of an illegitimate pregnancy. 

In certain cases the belief is not a result of suggestion, but a symptom 



CLINICAL PHEXOMEXA OF PREGNANCY 



51 



of true insanity. In other words, it is a delusion. This of course is 
quite a different matter. 

It is Hterally true that suggestion can in these cases " work wonders." 
All the presumptive symptoms of pregnancy can be evoked or accurately 
counterfeited under the influence of this mysterious power. Menstruation 
may cease, morning sickness may appear, the breasts increase in size, the 
abdomen may become distended and fetal movements may be simulated 
by movements of gas in the bowel, or by contractions of the abdominal 
muscles (Figs. ^2 and 33). The statements of the patient cannot be 




Fig. 33- — The same patient when anaesthetized. 

trusted, though she may be perfectly honest, and may sincerely believe that 
she is telling the truth. 

He who depends upon text-books and lectures alone will never be 
able to solve the problem, but will be in the humiliating position of being 
obliged to wait until weeks or perhaps months have solved the question 
for him ; but he who is familiar with the results of the bimanual exam- 
ination of early pregnancy need have no trouble, except possibly, in the 
first few weeks. If, for example, the patient states that she feels fetal 
movements, or that she has not menstruated for three or four months, 
and examination discloses the small, hard uterus of the non-pregnant 
condition, the question is settled. If the patient gives a history of an eight 



52 PREGXA^XY, LABOR AND THE PUERPERIU^I 

months' pregnancy, but no fetal parts can be recognized, no heart sounds 
heard, pregnancy does not exist. In other words, a competent examiner 
is to determine whether there are evidences in the uterus of changes 
corresponding to the alleged date of pregnancy. 

Trouble may arise if the patient is so stout as to make satisfactory 
external or bimanual examination impossible. Here, in early pregnancy, 
a recto-vaginal examination, under anesthesia if necessary, will solve the 
problem. Grasping the thick abdominal wall and moving it upon the 
structures beneath, may be sufficient to disprove the assertion of advanced 
pregnancy. In case of distention by gas. the latter disappears under 
anaesthesia, external, or bimanual examination becomes easy, and 
difficulties vanish. 

I have said that no reliance can be placed upon the statements of the 
patient. One thing, however, is to be remembered. If cross-examined 
she will often place the date of some important symptom, e.g., quickening, 
or the cessation of menstruation, so far back, perhaps ten or twelve months, 
that the hypothesis of pregnancy is at once seen to be untenable. 

Superfecundation and Superfetation. — Before leaving this subject 
brief mention must be made of two matters occupying the borderland of 
fable, and yet, perhaps for that very reason, possessing a certain fascina- 
tion for every student of obstetrics. I refer to superfecundation and 
superfetation. 

SuPERFECUXDATiox. — By this is meant conception in a woman already 
impregnated. For example, if a negro woman gives birth to twins, one 
of which is white and the other a mulatto, we may know that she has had 
intercourse with a white man. There is, however, no way of proving 
that she has had intercourse with a negro. The mulatto child may be 
simply the usual result of intercourse between a white and a black, while 
the white child may have failed to inherit any of the physical traits of its 
black mother, as is often the case. 

Superfecundation has been proven in the case of the lower animals, 
and there is apparently no physiological reason why it should not occur 
in man. Naturally it is difficult of proof. Williams reports the case of a 
woman who within a brief period had intercourse with two men one of 
whom had syphilis. She was delivered of twins, one of which was still- 
born, and showed placental and fetal evidences of syphilis. 

Schultze believes that superfecundation could only be absolutely proven 
by demonstrating the crossing of three races, e.g., by a negro woman 
giving birth to twins, one showing Caucasian, the other ]Mongolian descent. 

Superfetation. — By this term is meant a second conception occurring 
weeks or even months after the first, and resulting in the development and 
growth of a second foetus. Doubtless the idea of superfetation had its 
origin in the fact that, as we shall see in the chapter on multiple pregnancy, 
twins often represent different stages of development. 



CLINICAL PHENOMENA OF PREGNANCY 53 

Superfetation is hardly possible after the fourth month, since at that 
time the decidua reflexa and the decidua vera become united, and the 
entrance of spermatozoa is mechanically prevented. 

It is hardly likely to occur before that time because ovulation usually 
ceases during pregnancy. ^Moreover, as Bumm aptly observes, it has not 
been noted in cases of uterus duplex in which there would seem to be 
ever}^ facility for its occurrence were such occurrence possible. There 
have been, however, distinguished advocates of the possibility of 
superfetation. The great Tarnier believed that he had observed cases. 



CHAPTER III 

THE MANAGEMENT OF PREGNANCY 

Management 

The term management of pregnancy is not to be understood as imply- 
ing that normal pregnancy needs to be " managed " in the sense that we 
manage a pathological process. It is better to disabuse the mind of that 
impression at the outset ; the mind of the patient, as well as that of the 
physician. The patient should be told that she is not sick, that pregnancy, 
indeed, is the highest kind of health, and that she does not necessarily need 
any special regimen or any medicine. 

It is unfortunately true, however, that the pregnant woman is exposed 
to certain dangers that do not menace her non-pregnant sister, and that 
pregnancy too often occupies the borderland between health and disease. 
There are certain things to be avoided, certain danger signals for which 
one should watch. 

Pregnancy then does not necessarily need active interference, but 
it does need competent medical supervision. Before the rise of modern 
scientific obstetrics, the physician had but one interview with his patient 
before he saw her in labor. At this interview he sought to compute the 
expected day of confinement, and, perhaps, to arrange the matter of the 
fee.' When next he saw her, she might be in the throes of an eclamptic 
convulsion, or striving vainly to overcome the resistance offered by a 
contracted pelvis. 

It is unfortunately true that this custom, worthy of the days when 
the lying-in chamber was ruled by the midwife and the monthly nurse, is 
still all too common. It is, however, from every aspect, a bad one. Even 
the laity are now sufficiently well informed in medicine to know that it 
is absolutely without justification. Those physicians, if there are any 
such, who are governed only by selfish motives, should not forget this. 

The patient should be under the care of her physician during the entire 
period of her pregnancy. She should report to him at intervals of three 
or four weeks during the earlier months of pregnancy, and somewhat 
oftener during the last two months. She is fortunate if she has some 
judicious friend or relative of her own sex, a mother or married sister 
perhaps, in whom she can confide as occasion or inclination demands, not 
so much for instruction as for comfort, but with this exception she should 
discuss her case only with her physician. It is the experience of every 
practitioner that the prospective mothers among his patients are annoyed, 
and sometimes driven to the verge of hysteria, by the gossip of injudicious 
friends who not only give all kinds of advice, mostly bad, but relate 
cases of operations ending fatally, etc. 
54 



THE MANAGEMENT OF PREGNANCY 55 

There is, at the present time, a very prevalent tendency to regard 
obstetrics as a purely surgical specialty. This tendency should be dis- 
couraged. He who begins by studying the general health of his patient, 
examines her heart and lungs, learns her history and family tendencies, 
and is thus able to estimate her powers of resistance, and to stand guard 
at threatened points, will in the end make a better surgeon than he who 
is a mere mechanic. It is perfectly true that the obstetrician should have 
a good surgical training, but it is also true that he should have a good 
medical training, and that he should have been engaged for some years 
in the general practice of medicine. 

For example, it is highly important to discover nephritis or incipient 
tuberculosis early in pregnancy, when treatment may be of some avail. 
Neglect in this respect is sure to be avenged sooner or later. 

Special attention should be given to the anaemia and malnutrition 
so common in early pregnancy. These symptoms, combined as they often 
are with constipation and some exaggeration of the nausea and vomiting 
common at that time, are too often taken as a matter of course. Their 
neglect, however, may be a cause of serious trouble later. That they 
ever should be neglected is unfortunate, for they are very amenable to 
treatment by suggestion, diet, fresh air, oxygen, chalybeate tonics, etc. 

During the entire course of pregnancy the physician should remember 
that intercurrent and complicating diseases, while not common, do some- 
times occur, and that not everything that happens at this time is necessarily 
a complication of pregnancy per se. 

In a general way the matters that should engage the attention of the 
physician may be summarized as follows : 

1. The general physical condition of the patient. 

2. The hygiene of pregnancy proper, including such matters as diet, 
dress, bathing, exercise, etc. 

3. Attention to certain matters of prophylaxis. This is perhaps the 
most important of all. Prophylaxis is the key to the management of 
pregnancy. Illustrations of this are to be found in the prevention of 
eclampsia by the prompt recognition and treatment of the toxaemia of 
pregnancy, the recognition of discovery of pelvic contraction or other 
anomaly at the antepartum examination, the prevention of abortion by 
suitable precautions, etc. 

The General Health of the Patient 
When the physician sees his patient for the first time early in pregnancy. 
his first duty is to inform himself as to her general health, and especially 
as to the condition of her heart, lungs and kidneys. The knowledge gained 
in this way is far more important than anything that is usually discovered 
at this time by vaginal examination. 

As we shall see later, regular examinations of the urine should be 
made from the beginning. I emphasize this here, at the risk of being 



56 PREGNANCY, LABOR AND THE PUERPERIUM 

accused of repetition, because I believe that there are some things that 
should be so fixed in the mind of the man who would practise obstetrics, 
that he cannot forget them if he will. 

General Mode of Life. — Taking up now what I have ventured to call 
the hygiene of pregnancy, let us return to the proposition that pregnancy 
is not a disease, and that it does not necessarily require active treatment. 
From this it follows that the patient need not make any radical change in 
her method of living. Indeed, it is probably better that she should not 
import into her life at this time any new and untried elements. An excep- 
tion to this rule, however, is to be found in the case of certain patients of 
the neurotic type, and in the neurotic type of the vomiting of pregnancy. 
Here a complete change of air, scene and habit may work wonders. 

Diet. — The pregnant woman needs no special system of diet. What 
she does need, is a mixed diet of plain and nutritious food, of good quality 
and sufficient quantity. In view of the increased demands upon the 
eliminative organs, it is perhaps well to limit red meat to one meal a day, 
and to substitute fish or fowl for meat two or three times a week. It is 
also well for the patient to drink plenty of water, and to eat a good deal 
of fruit, thus favoring elimination and combating the tendency to consti- 
pation so common during pregnancy. Recalling the great demand for lime 
salts at this time, and the disastrous effect of their limitation, it seems 
plain that they should be plentifully supplied in the diet. Bread from the 
whole wheat is to be preferred to bread made from ordinary white flour, 
and its sustaining effect is always appreciated by the patient. The baker's 
bread sold in our large cities contains little nourishment. Articles that 
are known to disagree with the patient should be sedulously avoided. An 
attack of acute indigestion during pregnancy may prove a serious matter 
and abortion may result. Sweets and desserts are to be taken with 
moderation. Alcoholics are to be avoided unless specially indicated. 

As regards the frequency of meals and the amount of food to be 
taken, the appetite of the patient is, within reasonable limits, the best 
guide. It is folly to refuse sufficient nourishment to a woman who must 
provide not only for her own necessities, but for those of her living and 
growing child. A great deal of good may be done by allowing the patient 
a light meal just before retiring, or in the middle of the night, if she feels 
the need of it. Sleeplessness and nervousness in pregnant women are 
often due to an empty stomach. Starvation as a preparation for labor and 
lactation is certainly irrational. Schemes of reduction advocated in books 
written for the laity are to be regarded with suspicion. If fear of 
toxc-emia or kidney complication exists the patient may at least have plenty 
of milk, which is not only a good food but a good diuretic as well ; but 
one should remember and guard against the constipating effect of an 
exclusive milk diet. 

Special diet may, of course, be necessary for special conditions, e.g., in 
toxaemia, and in diabetes, and Prochownik has advised a special diet for 



THE :\IAXAGEMENT OF PREGNANCY 57 

certain cases of pelvic contraction. Each of these will be discussed in its 
appropriate place. 

Exercise. — Barring complications, a reasonable amount of out-of-door 
exercise is as necessary during pregnancy as at any time, perhaps more so. 
On the whole, walking in the fresh air is the best. It should not, however, 
be carried to the point of fatigue. It may and should be continued up to 
the very onset of labor, and is especially useful in primiparae, promoting 
the descent and engagement of the head, and the expansion of the lower 
uterine segment. If the patient is easily fatigued the walks should be 
short, with intervals of rest. 

Long standing, however, should be absolutely forbidden, since it 
unquestionably tends to promote the development of varicosities, or the 
increase of those already existing. In rare cases it may cause the rupture 
of a varicosity with profuse and dangerous hemorrhage. 

If there is no special contra-indication the patient may busy herself 
with light housework. Indeed it is far better that she should be thus 
occupied than that she should sit idly by in morbid preoccupation. Here 
also, however, overexertion and long standing should be avoided. She 
should never attempt to lift heavy objects, or move heavy articles of 
furniture, especially in the latter months of pregnancy. Such imprudences 
may result in premature rupture of the membranes. There is a popular 
tradition that a patient should not reach up after high objects. All 
unusual or violent exercises should be tabooed. Bicycling, tennis, horse- 
back riding, or carriage riding over rough roads, long railroad or trolley 
car journeys and the like, should be forbidden. It is true that these 
things do not always result badly, but they are not necessary to the health 
of the patient, and they always involve the risk of abortion. On the other 
hand, automobiling over smooth roads for periods not too long is often 
beneficial. 

For those who for some reason must remain in-doors, or even in bed, 
passive resistance movements and massage aid materially in promoting 
the general nutrition. 

Fresh Air and Oxygen. — The pregnant woman should have an 
abundant and constant supply of fresh air. She should spend as much 
time as possible out-of-doors and her bedroom should be well ventilated. 
When she cannot go out or will not leave the house, she can rest or sleep 
upon an open veranda during the day, or even at night. She should 
avoid all ill-ventilated rooms and all crowded places. I believe that the 
occasional inhalation of oxygen is highly beneficial even in cases approxi- 
mately normal. Slight subjective dyspnoea is very common during preg- 
nancy, and both theoretical and practical considerations indicate the need 
of oxygen in one form or another. My own views upon this subject will 
be found in the chapter on the toxaemia of pregnancy. Suffice it to say 
here, that I believe that what I may call the out-door management of 



58 PREGNANCY, LABOR AND THE PUERPERIUM 

pregnancy will some day be recognized as the most important factor in 
the care of patients during this period. 

Sleep. — It is highly important that the pregnant woman should have 
an abundant supply of sleep and if, as frequently happens, her sleep is 
disturbed at night, she should make up for this by sleeping in the day- 
time : in an airy chamber, or still better, out-of-doors. If inclined to doze 
in the morning she should not be disturbed. With many women it is the 
nervous system that suffers most during pregnancy. Nervousness and 
despondency are always exaggerated by loss of sleep and its effect in this 
respect is even more marked in pregnancy than at other times. 

Bowels. — Constipation is so common during pregnancy, that one is 
tempted to think of it as an incident, rather than a complication. Mild 
cases may be treated by laxative articles of diet and by drinking a glass 
of water before breakfast. Of medicines, the best in my experience is 
cascara, in one form or another, given every day or every other day for a 
time. The result of the first dose is often unsatisfactory, and the patient 
should be informed of this in advance. Thirty to sixty drops of the 
fluid extract, or three to five grains of the solid extract, may be given at 
bedtime. The size of the dose, and the frequency of its administration, 
must be determined by experiment. When the proper medium has been 
reached, however, this drug will be found very satisfactory. It produces 
natural movements, does not deplete the patient as do the salines, and, 
above all, has no tendency to produce abortion or premature labor. When 
an immediate movement is desired we may begin with the effervescent 
citrate of magnesia, which is mild, pleasant to take, and usually efficient. 

The stronger salines which produce copious watery movements should 
be reserved for cases in which they are distinctly indicated, e.g., certain 
cases of toxaemia. Depleting measures are usually contra-indicated in 
pregnancy, and especially in early pregnancy. Pregnant women are often 
advised by their friends to take " salts," but the practice is a bad one. 

Castor oil should never he given during pregnancy unless the induction 
of labor is contemplated. In the later months, a single dose of this drug 
is often sufficient to produce this effect. I have found that this important 
fact, so familiar to the monthly nurse, is unknown to many physicians, 
and even to some writers on materia medica. 

Sexual Intercourse. — It is perhaps impracticable to prevent sexual 
intercourse during the entire period of pregnancy, but it should be prac- 
tised, if at all, with great moderation and restraint. It may result in the 
interruption of pregnancy if the patient is predisposed to abortion. In 
the latter weeks it should be avoided altogether, since it may be the cause 
of infection. I recall one case of placenta prsevia, previously unsuspected, 
in which a fatal hemorrhage was the immediate result of sexual intercourse. 

Clothing. — All clothing should be loose and comfortable. The ordi- 
nary corset should not be worn after the uterus can be felt above the 
symphysis ; i.e., after the third month. Tight corsets impede respiration 



THE [MANAGEMENT OF PREGNANCY 59 

and interfere with the pelvic circulation. In the later months of pregnancy, 
however, if the abdomen is pendulous or prominent, or if the patient 
complains of the weight of the uterine contents, an abdominal supporter 
may altord great comfort, and perhaps prevent diastasis of the recti 
muscles. The weight of skirts should be suspended from the shoulders, 
not from the waist. Circular garters should be avoided, as tending to 
cause varicosities or to aggravate them if present. 

Sufficient clothing to prevent chilling should be worn, but there is 
no necessity for the overdressing sometimes recommended. Undercloth- 
ing should be of some porous cotton or linen mesh material which provides 
for elimination by the skin, and is thus far superior to the old-fashioned 
all-wool garments. 

Bathing. — This is obviously important during pregnancy, not only 
because it favors elimination, but also as a tonic and general invigorator, 
and stimulant of metabolism. The genitalia should be washed daily with 
soap and water during the latter weeks of pregnancy, but no douches 
should be taken without the express order of the physician. In normal 
cases they are quite unnecessary, and are, in themselves, likely to cause 
infection. Scrupulous external cleanliness, however, is of undoubted value 
as a preventive of infection, especially of infection by the colon bacillus. 
This statement applies not only to infection during labor, but also to those 
cases of infection that are occasionally noted during pregnancy, and 
particularly to pyelitis. 

Care of the Nipples. — The application of solutions of alcohol, tannic 
acid, and other astringents, to the nipples, for the purpose of hardening 
them, and thus preventing the development of erosions and fissures, is 
widely practised. A nipple that is soft and supple is less likely to become 
cracked than one that has been artificially hardened, if indeed the latter is 
possible. Nor do I beliei^e that benefit is derived from keeping the nipple 
smeared with ointments and salves that are seldom sterile, or, if they are, 
cannot long remain so. 

I agree with the late Dr. Tucker, of the Sloane Maternity Hospital, 
that simple cleanliness, i.e., washing the nipples daily with soap and water, 
is all that is necessary. This serves to remove the crusts that otherwise 
gather and that predispose to erosions. All pressure from corsets and 
other clothing should be carefully avoided, and the nipples should be 
freely exposed to the open air whenever circumstances permit. 

If the nipples are not sufficiently prominent, they should be drawn 
out daily during the latter weeks either by the fingers or breast pump. The 
latter is the more effectual. 

Let me here emphasize the fact that much more depends upon the 
proper treatment of the nipples during the first few days of the puer- 
perium, than upon any special treatment employed during pregnancy. 
This important subject will be discussed in connection with the management 
of the puerperium. 



60 PREGNANCY, LABOR AND THE PUERPERIUAI 

The Teeth. — For every child a tooth. So runs the ancient legend — a 
legend founded upon fact. Wt have already seen that the maternal 
organism must supply calcium for the foetus. This the mother can often 
ill afford to spare. The teeth should be regularly and carefully brushed, 
and some preparation which is both alkaline and antiseptic, e.g., alkalol, 
used as a mouth wash. The diet should be rich in phosphates, such articles 
as oatmeal and whole wheat bread being furnished in abundance. The 
syrup of lactophosphate of lime, or some similar preparation, is indicated. 
Good dental advice should be obtained. If the patient is not extremely 
nervous or sensitive, manipulations that are not prolonged or painful, 
e.g., the insertion of temporary fillings, are not contra-indicated. Pro- 
cedures attended by severe pain are better postponed if practicable. 

Examination of the Urine. — Regular examinations of the urine should 
never be neglected. Such examinations should be made every two or three 
weeks during the first six months, and during the last three months when 
toxaemia and eclampsia are most likely to develop, every week. The 
neglect of these examinations is highly reprehensible, and may result in 
disaster to the patient, and deserved criticism of the physician. The latter 
should not be satisfied with the chemical examination, but should invariably 
inquire as to the quantity passed. IMany men forget all about this, but it 
is obvious that a considerable diminution in the total quantity of urine is 
a much more serious matter than any ordinary change in its composition. 
\\'henever there is any doubt, the quantity passed in twenty-four hours 
should be measured. This subject will be considered again in connection 
with the toxaemia of pregnancy. 

When practicable, the examination of the urine should be accom- 
panied by measurement of the blood-pressure. It is true that marked 
oscillations in the blood-pressure may occur during pregnancy without 
appreciable disturbance, but the procedure is nevertheless a wise one as 
affording valuable corroborative evidence. 

Mental Hygiene, — Last, but by no means least, I would place the 
psychical treatment, or, as I have been accustomed to call it, the mental 
hygiene of pregnancy. 

As noted in the last chapter, there are some women who feel better 
during pregnancy than at any other time. These cases, however, are 
exceptional. The majority of patients are, to a greater or less extent, 
psychically depressed during the early months of pregnancy. While 
there is no actual ground for this depression, as the patient will herself 
usually admit, it is nevertheless a very real thing to her. 

This condition calls for the greatest forbearance and consideration. 
The patient should be informed that her condition is the result of the 
physical disability incident to early pregnancy, that many other women 
are affected in precisely the same way, and that a change for the better 
is sure to follow. Her husband and family should be informed that 
ner\'ousness and irritability, if present, are the result of her physical 



THE i\IANAGEMENT OF PREGNANCY 61 

condition, and are on no account to be met with argument and attempts 
at repression. Every reasonable desire should be granted, and every 
unreasonable one, the fulfillment of which will do no great harm. Any 
harmless amusement or diversion may prove beneficial. If these methods 
do not succeed, change of air or scene may be found the one thing needful. 

Prophylaxis. — In the management of pregnancy, prophylaxis is of 
prime importance. For example, eclampsia, the most formidable compli- 
cation in obstetrics, may almost always, if not always, be prevented by 
the timely recognition and treatment of the symptoms of toxaemia. 

Placenta prcXvia, another and a justly dreaded complication, need 
hardly ever result fatally, if the patient is properly watched during preg- 
nancy. Hence the importance of instructing the patient to report any 
loss of blood, especially if it be painless. A slight hemorrhage is often 
regarded as of no great consequence, provided it is not accompanied by 
pain. but. we shall see when we come to the study of placenta praevia, 
painless hemorrhage is always of serious import. 

Hemorrhage accompanied by severe pain usually indicates impending 
or actual abortion, a much less dangerous condition but one which brings 
an urgent call for medical aid. And with reference to abortion, this 
unfortunate ending of pregnancy may often be prevented. 

If pregnancy be complicated by gonorrhoea, it is of the utmost impor- 
tance that the attendant be aware of this fact, since, as we shall see later, 
there is much that can be done in these cases, not only to make labor safer 
for the mother, but also to prevent infection of the child's eyes. 

In view of the frequent need of catheterization in the first few days 
following delivery, and the harm occasionally resulting from this, it is well 
to advise the patient that she should become accustomed to urinating in 
the recumbent position during the latter days of pregnancy. 

x\nd so one might go on, if space permitted. These examples, however, 
will sufiice to suggest to the reader the need of independent study in this 
direction. 

I have already emphasized the importance, from the standpoint of 
prophylaxis, of becoming acquainted as early as possible with the history 
and general physical condition of the patient. The importance of an ex- 
amination, at some time during the last few weeks of pregnancy, cannot 
be overestimated. Its prophylactic value is often far greater than that of 
an examination during labor and its neglect a most serious defect in 
obstetric practice. Worthy of note in this connection is the suggestion 
that the same precautions against infection be taken as during labor. 

It is true that the internal examination at this time involves the least 
danger but in many cases labor may be already in progress, its onset not 
having been recognized, and consequently a serious or fatal result is possi- 
ble. From the beginning of cervical dilatation we have a surface favorable 
to the direct absorption of septic matter. 

Following out this line of thought, it becomes evident that since the 



62 PREGXAXCY, LABOR AXD THE PUERPERIU^I 

physician cannot be with his patient all the time, he should inform her 
of those danger signals which he, if present, would not neglect. I am 
accustomed to instruct my patient to report to me any change in her 
condition, or any unusual symptoms, especially the following: diminution 
in the quantity of urine, increased vaginal discharge or any gush of fluid, 
bleeding from the vagina however slight, headache, dimness of vision or 
spots before the eyes, swelling of the feet or face, any nausea or vomiting 
after the cessation of the usual morning sickness, epigastric or abdominal 
pain, obstinate constipation, etc. In some cases it may be better not to 
annoy the patient with these directions, but to give them to some 
responsible member of her family, or to the nurse if there be one in 
attendance. 

Experience has taught me that it is never safe to wait until notified 
by the patient of the existence of some of these symptoms. To* do this 
is, in some cases, to wait too long. Some of the most dangerous symptoms, 
e.g., swelling of the face, and the early hemorrhages of placenta prsevia, 
are not productive of pain or discomfort, and are often overlooked. As 
stated above, the patient should be seen at intervals, and at these interviews 
the attendant should satisfy himself, by careful questioning, and, so far 
as practicable, by actual examination, that threatening symptoms are not 
present. 

All this takes but little time, and may be productive of untold good. 
Its main object of course is to forestall compHcations, but it also serves 
to reassure the patient, who soon learns that her physician is really inter- 
ested in her welfare. It tends to establish the reputation of the physician 
as a careful man who uses modern methods, and, what is more important, 
it enables him to feel that he has not been unworthy of the responsibility 
committed to him. 



CHAPTER IV 
THE ANTEPARTUM EXAMINATION 

As indicated in the previous chapter, the physician should make it his 
first duty to become famihar with the history and general physical con- 
dition of his patient. But this is by no means all. Every man who 
assumes the responsibility of caring for a woman in labor, should inform 
himself, before labor begins, as to whether there is anything in the condition 
of mother or child that may delay or complicate the process. This can 
only be done by actual examination. The prophylactic value of such an 
examination is very great. For example, the patient may be the subject 
of pelvic contraction sufficient to cause serious dystocia, and yet she may 
present no noticeable deformity whatever. If the condition is recognized 
in time, premature labor may be induced, or arrangements made to operate 
early in labor, before exhaustion or possible infection make the Csesarean 
section more than usually hazardous. 

\'arious other conditions — malpositions and malpresentations, unusual 
size of the foetus, placenta praevia, tumors that may obstruct delivery, 
venereal diseases with the accompanying danger of maternal infection and 
fetal ophthalmia, and many other conditions which need not be 
enumerated here, but which are all amenable to curative treatment. 

This examination has become known in hospital parlance as the ante- 
partum examination, and as such deserves separate and careful considera- 
tion. Its importance is twofold. It safeguards the patient against many 
dangers, and it familiarizes the physician with the external diagnosis 
of position and presentation, a subject of vast importance, which can 
be much better studied at this time than during labor, when the patient 
is sensitive to all manipulations, and the retraction and thickening of the 
uterine wall, especially after rupture of the membranes and escape of the 
liquor amnii, makes examination difficult. 

He who intends to do much obstetrical work should embrace every 
opportunity of perfecting himself in this method of examination. With 
continued practice, he will be astonished to learn how much can be accom- 
plished. Moreover, while it is best learned during the latter weeks of 
pregnancy, it can usually be practised during labor, between contractions. 

Another important advantage gained by this examination is, that it 
often makes an examination early in labor quite superfluous, thus lessening 
the danger of infection and making immediate examination at the time 
of labor unnecessary. For example, if in the case of a primipara the 
antepartum examination has shown that there is no contraction of the 
pelvis, that the head is in the pelvic cavity, and that everything else is as 
it should be, and if the patient is attended by a good nurse, who reports 

63 



64 PREGXAXCY, LABOR AND THE PUERPERIUM 

that the ''pains" resemble in character and frequency those of the first 
stage, there is obviously no great occasion for haste, and no great necessity 
for internal manipulations. 

To my mind, the importance of this work is underestimated by students 
and teachers alike. How much time is spent in the study of the physical 
diagnosis of cardiac and respiratory diseases in the adult, often indeed 
when the matter is of academic interest only, and how little in the study 
of the physical diagnosis of pregnancy, a subject of far greater practical 
importance. 

^^dlen should this examination be made? Preferably, from two to 
four weeks after the period of viability of the child has been reached, 
i.e., when the patient is from seven and one-half to eight months pregnant. 
At this time it is not too late for the induction of labor, should this be 
found advisable. If the pelvis is measured at this time, further examina- 
tion will not be necessary, unless some complication is discovered. x\n 
external examination, however, a week or two before the expected date 
of labor, is highly desirable. At this time, the fetal outlines are much 
more easily made out, and the position and presentation accurately deter- 
mined. ^Moreover, in the case of a primipara, it is important to determine 
whether the head has entered the cavity of the pelvis. 

Technic. — The patient should be in the dorsal position, upon a firm 
mattress, or preferably, a table. In order that the greatest relaxation of 
the abdominal muscles may be secured, the knees should be moderately 
flexed, and the head and shoulders slightly raised. It is desirable that 
the bladder and bowels be empty. Table or mattress should be of con- 
venient height. If the examiner is obliged to stoop, his movements will 
be constrained and he will be more liable to error. ^Moreover, in feeling 
the promontory of the sacrum it is often necessary to sink the elbow 
almost perpendicularly, and this is impossible, or at least very difficult, 
when the patient is near the level of the floor. Corsets should be removed 
and clothing so arranged that the abdomen can be exposed from the 
xiphoid to the symphysis. The object of the procedure should be 
explained to the patient, who may usually be truthfully told that it will 
be attended by httle or no pain. 

Inspection. — The practiced eye takes note of many things. Unusual 
size of the abdomen suggests contracted pelvis, hydramnion, twin preg- 
nancy, or a ver}^ large foetus. Great prominence of the abdomen in a 
primipar-a reminds one of contracted pelvis, as does also a pendulous 
abdomen in a multipara. In transverse positions the fact that the long 
axis of the uterus is transverse is often apparent to the eye. Fetal move- 
ments may often be seen through the abdominal wall. Operative scars 
should not escape attention. 

Palpatiox. — It is best, especially for the beginner, to preser^^e a 
definite order. This conduces to systematic and careful work. The 
external examination should aki'ays precede the internal The latter 



THE AXTEPARTUAI EXAMINATION 



65 



supplements and confirms the former. As a rule, the external examina- 
tion attords more information than the internal, and in many cases it 
makes the latter quite unnecessary, e.g., if in the case of a primipara 



^1^1^^^ 





( 




k ■■-.:- 



Fig. 34. — Outlining the fundus. 



the head is found well down in the cavity of the pelvis, and the measure- 
ments of the pelvic outlet are normal, it is quite unnecessary to subject 
the patient to the ordeal of a careful internal pelvimetr}^ Likewise, in 



66 PREGXANXY, LABOR AND THE PUERPERIUM 




Fig. 35- — Usual method of palpating the abdomen. The palms of hands are used. 




Fig. 36. — A better method. The finger tips are used. 

the case of a multipara, if the external examination discloses normal con- 
ditions, and the patient gives a reliable history of easy deliveries, one 
may dispense with the internal examination. 



THE ANTEPARTUM EXAMINATION 



67 



All manipulations should be gentle. The great mistake of the beginner, 
and sometimes of those who should know better, is to make strong pres- 
sure, which is annoying or even painful, and which the patient involun- 
tarily resists. Use the tips of the fingers and not the flat of the hand. 

It is best to begin by outlining the fundus (Fig. 34). This is done> 




Fig. 37. — Vertex presentation; palpation of the small parts. 

not, as is so often supposed, to map out the breech, but to determine the 
height of the fundus, and thus to be able to estimate the probable period 
of pregnancy. The breech has no characteristic outline, and is best located 
by determining the position of the head. If the examiner knows the 
position of the head, he should have little difficulty in determining that 
of the breech. As we have already seen, the uterus is usually in a position 



68 



PREGNANCY, LABOR AND THE PUERPERIUAI 



of right obliquity. It is well to correct this by gently carrying the fundus 
to the median line. After this has been done it is often observed that the 
fundus is really higher, and pregnancy probably farther advanced than 
was previously supposed. 

The Fetal Back. — The next thing to do, is to determine the long 
axis of the foetus, thus making sure that we are not overlooking a trans- 




FiG. 38. — Vertex presentation; palpation of the back. 

verse position. This is not usually necessary, the contour of the abdomen 
bemg sufficiently plain to the experienced eye, but it is always a wise 
precaution for the beginner. 

It is now in order to locate the back of the foetus. This is recognized 
as a broad resistant surface immediately beneath the abdominal wall, and 
extending over a large part of one lateral half of the abdominal area. 
It is best appreciated by using only the pulps of the finger-tips and applying 



THE ANTEPARTUM EXAMINATION 



69 



these very gently (Figs. 34, 35, 36, 37 and 38). One often sees most 
unskilful manipulations, prodding with the fingers, pushing with the palm 
of the hand, etc. After a little practice with the correct method, one need 
have no trouble at all. unless the abdominal wall is very thick. 

On the side opposite the back, the characteristic resistance will be 




Fig. 39. — Palpating the shoulder in vertex presentation. 

absent. Indeed the best way for the beginner to learn how to recognize 
the back is to palpate the abdomen, first on one side then on the other. 
In this way he cannot fail to appreciate and remember the sensation 
conveyed to the palpating fingers. Not only is the abdomen softer on 
the side opposite the back, but fetal parts may ustially be felt. This is 
not always the case, however, nor is their presence necessary to the 
diagnosis. The student soon becomes familiar with these *' small parts," 



70 PREGNANCY, LABOR AND THE PUERPERIUM 

as small, irregular, and moving protuberances which can be not only felt, 
but seen to move, through the abdominal wall, especially if the latter is thin. 
As we shall see later, their presence in front, near the median line, is 
evidence of a posterior position of the occiput. 

The palpation of the fetal back is of great importance. It tells whether 
the occiput points to the right or left, anteriorly or posteriorly, earlier and 
better than this can be determined by vaginal examination ; long, indeed, 
before the beginning of labor. It also tells us where to look for the fetal 
shoulder, and where to listen for the fetal heart. Conversely, of course, 
the fetal heart, of which we shall speak presently, helps to locate the back 
and shoulder. In left positions of the occiput, the back is on the mother's 
left side, and in right positions, on the right. In posterior positions, it is 



II 



\- 



Fig. 40. — Measuring height of the anterior shoulder above the pelvic brim. 

much farther from the median line than in anterior positions. The exam- 
iner should remember that the R. O. P. position is, next to the L. O. A., 
the most common position. 

The Fetal Shoulder. — Having determined the position of the back, it 
is well to locate the anterior shoulder (Fig. 39). This is a matter of 
considerable importance, and one very commonly neglected. Most teach- 
ing, both text-book and clinical, is very deficient in this respect. I am 
accustomed to say to my students, that when they can locate the shoulder 
in a case of average difficulty, they have become fairly proficient in the 
external examination of pregnancy. 

There are two methods. In the first the fingers are carried downward 
along the dorsal plane until a sudden depression is encountered. This 
depression is the neck, and just above it, is the shoulder. The latter is 
felt as a small knob-like projection, fixed, or at least not as movable as the 



THE AXTEPARTUIM EXAMINATION 



71 



'•' small parts " already mentioned. Another method, and one which I 
myself have found very useful, is first to locate the head, and then carrj^ 
the fingers upward until the shoulder is felt. 





D=I5 



cm 



i^'^^^-'f 



■X 





Fig. 41. — Measuring the distance of the anterior shoulder from the median line 
in R. O. P. position. 





Fig. 42. — Measuring the distance of the anterior shoulder from the median line in L. O. T. 
position. The cross also corresponds to the maximum intensity of the fetal heart. 

Of course the shoulder cannot always be felt ; but it can be felt in the 
majority of cases. Fabre has estimated that it can be recognized in 
about ninety per cent, of all cases and this corresponds with my own 
experience. Its recognition is easier in primiparse than in multiparie. 



72 PREGNANCY, LABOR AND THE PUERPERIUM 





Fig. 43. — Locating the shoulder. 



Note that it is far above the pelvic brim, showing that the head has 
not engaged. Position R. O. A. 



Among the causes that sometimes prevent its recognition are hydramnion, 
twin pregnancy, death of the foetus, prematurity or small size of the foetus, 
and thickness of the abdominal wall. 



THE ANTEPARTUAI EXAMINATION 



73 



\\'hat is gained by 



^ locating the shoulder? There are several advan- 
tages. In the first place, it aids very materially in determining the relation 
of the head to the pelvic brim. Careful observations have shown that 



^P^ 



!*" 



V- 




#- 





Fig. 44.— Locating the shoulder. The same patient three weeks later. Note the shoulder is less than 

seven centimetres above the pelvic brim. 

the average distance between the greatest diameter of the fetal head. rh.. 
the biparietal diameter, and the shoulder, is about seven centimetres. It 
follows, that if the shoulder is much more than seven centimetres above 



74 PREGNANCY, LABOR AND THE PUERPERIUM 

the brim, it has not engaged, whereas if the distance is much below this 
its engagement is certain (Figs. 40, 41 and 42). 

It is quite true that when the head is far above the brim, or deeply 
engaged in the pelvis, we do not need confirmation of the fact ; but there 
are certain cases in which it is difficult to determine its exact location, 




Fig. 45. — Bimanual palpation. Note that the finger tips alone come in contact with the head. 

and, in these, I have found a knowledge of the position of the shoulder 
of the greatest value (Figs. 43, 44 and 45). 

Again, the location of the shoulder affords valuable confirmatory 
evidence of the position of the occiput, for experience shows that the 
shoulder is about twice as far from the median line in posterior, as in 
anterior, positions. 



THE ANTEPARTUM EXAMINATION 



75 



Then, too. in doubtful cases, a knowledge of the position of the 
shoulder may aid us in our search for the fetal heart. It has been shown 
that the site of maximum intensity of the heart sounds corresponds quite 
closely with the position of the shoulder. 



^ 



f|-~;-t^|^ 







^' 





Fig. 46. — Palpating the fetal head above the brim. Bimanual method. 



Let me impress upon the mind of the reader that the palpation of 
the fetal shoulder, so commonly neglected, is not an unnecessary refinement 
of diagnosis, but a measure of undoubted clinical value. 



7^ 



PREGNANCY, LABOR AND THE PUERPERIUM 



The Fetal Head. — We now come to the palpation of the fetal head, 
perhaps most important of -all. The head is recognized as a large globular 
body communicating to the palpating fingers a sensation of solidity and 






\ 



Fig. 47. — Palpating the head by the unimanual method. 



hardness, quite different from that of any other part of the foetus. Let 
the student familiarize himself with this at the outset. If the practitioner 
has not done so, let him begin now. It is a matter of prime importance, 
indeed it is an absolute necessity, that every obstetrician should be able to 



THE AXTEPARTUAI EXAMINATION 



77 



recognize the fetal head by palpation, to determine whether it is above 
or below the brim of the pelvis, and if it is absent from its usual position 
at the brim or in the cavity, to recognize the fact. It is as important to 
dctcnninc its absence as its presence, for the absence of the head from its 
usual position constitutes the one immediate and positive evidence that: 




Fig. 48. — Unimanual palpation; head movable. 



the obstetrician has to deal with a breech presentation or a transverse 
position. 

How shall we palpate the head? In the first place, let the beginner 
remember that, in the last few weeks of pregnancy, he will find the head 
above the brim in multiparae, and in the cavity in primipara^. Since most 
of our patients are multiparae the head will, in the majority of cases, be 



7^ 



PREGXA^XY, LABOR AND THE PUERPERIUM 



found above the brim. This is true not only of pregnancy but as we shall 
see later of the first stage of labor. Let us first look for it, then, where we 
shall ordinarily find it, just above the brim of the pelvis. 

The method of palpating the head above the brim is shown in Figs. 46 



W 




^'^fi^^;rtTi^o^r?.t '^u^? ^^ ^'^- 47.. three weeks later. Note that the examiner is obliged to sink his 
nnger tips a httle below the pelvic brim. The unimanual method can no longer be employed. 

and 47. The tips of the fingers of both hands are placed as in the illus- 
tration, and the abdominal surface is depressed. The patient should be 
thoroughly relaxed, and there should be no sudden or rough movements. 
These always excite resistance and defeat the object of the examination. 



THE ANTEPARTUM EXAMINATION 79 

If the abdomen is depressed very slowly and gently, the patient need 
suiter no great inconvenience. The tips of the fingers are then brought 
together from side to side and the head is found between them. The mis- 
take of the beginner is to bring the fingers together too soon, thus missing 
the head. 

Figs. 48 and 49 show another method. One hand only is used. This 
method is not applicable when the head is deeply engaged, but is very 
useful and convenient when the head is floating above the brim. Note that 
the thumb and index finger are actually between the head and the 
symphysis pubis. Fig. 49 shows a case in which a small segment of the 
head has entered the pelvic brim. " The head has engaged." Here flexion 
is more marked. Note the greater prominence of the forehead, and that 
on the right side one can follow the great convexity of the forehead 
and face for a comparatively long distance, while on the left one can palpate 
only a small segment of the occiput. Remember that this fact is an aid in 
diagnosis, i.e., in distinguishing between a right and a left position. The 
beginner will find such cases the most difficult. It is necessary to carry the 
fingers well down into the cavity of the pelvis but they cannot be carried 
below the head. Nevertheless, with a little practice the head can be 
recognized. In this case pressure is not made directly downward, i.e., 
toward the floor, but diagonally forward, in the axis of the pelvic canal. 

It is an absurdity to try to outline the breech which has no very charac- 
teristic outline. When the head, shoulder, and back have been located 
there should be no difficulty in locating and palpating the breech. Nor 
is it necessar}^ to locate the small- parts, in anterior positions, since if we 
know where the head, back, and breech are, we know where the small 
parts must be. The recognition of the small parts in front, however, 
is, as already noted, valuable confirmatory evidence of a posterior position 
of the occiput. 

The Fetal Heart. — In 1818, Mayor, of Geneva, made the epoch-making 
discovery that the fetal heart can be auscultated through the abdominal 
wall. It seems strange that the world had to wait so long for this dis- 
covery, but not more strange perhaps than that even now so many men 
who call themselves obstetricians fail to avail themselves of it. Every 
student and practitioner should take advantage of every opportunity to 
listen to the fetal heart. He should never forget that he has two patients 
under his care, and that it is his duty to keep himself informed as to the 
condition of both. 

There are two methods of auscultating the fetal heart — the direct 
method, in which the ear is applied to the abdomen, and the indirect 
method, in which the stethoscope is used. It is absolutely necessary that 
both methods should be learned. 

The indirect method is usually the most convenient, and the sound-^ 
can be better localized with, than without, the stethoscope. 



80 



PREGXAXCY, LABOR AXD THE PUERPERIUM 



The direct method, however, has certain important advantages. It can 
be used when one has no stethoscope at hand. ^Moreover, during forceps 
operations and versions the operator should not contaminate his hands by 
touching the stethoscope. It may be noted in passing that the French have 
devised a stethoscope that can be steriHzed (Fig. 50). 

In using the direct method the ear is appHed closely, but not heavily, 
to the abdomen, which is first covered by one layer of gauze ; not by a 
towel, as is often suggested. Xo one who knows much about the fetal 
heart will try to hear it throug-h a towel. 




Fig. 50. — Monaural stethoscope; made of aluminum and can be boiled for use during labor. 

In using the stethoscope, one should not touch the instrument with the 
hands, but should keep it applied to the abdomen by a rubber band. This 
simple manoeuvre, famihar to the house surgeons in maternity hospitals, 
excludes many undesired vibrations, and simplifies the matter more than 
one would suppose. In either case absolute silence should be m.aintained 
in the room (Fig. 51). 

What does the fetal heart sound like ? Perhaps the familiar comparison 
of a watch under a pillow is as good as any, but no description is satis- 
factory. In order to know what the fetal heart sounds are like, one must 



THE AXTEPARTU:\I EXAMINATION 



81 



listen to the fetal heart. 



Opportunities are frequent, and there is no other 

The 
sound is a double one, svstole and diastole, as in the adult, but the interval 



^^■ay. The rate averages between 120 and 160 beats per minute 








Fig. 51. — Listening to the fetal heart without touching the stethoscope. 

between the pairs of sounds is so short that it is only recognized with care, 
and the beginner always thinks of the fetal heart sound as a single one.^ ^ 

Where is the fetal heart best heard ? This depends upon the position 
of the foetus, and the period of pregnancy. In the eighth and ninth months 
6 



82 PREGNANCY, LABOR AND THE PUERPERIUM 

of pregnancy, and in the L. O. A. position — in other words, in about sixty- 
five per cent, of all cases — it will be heard most plainly on the left side, 
about half-way between the umbilicus and the anterior-superior spine of 
the ilium. It is almost universally taught that in the R. O. A. position 
the maximum intensity of the fetal heart sounds will be at the same 
relative point on the right side. This is a palpable error. A moment's 
reflection will show that in right positions the left side of the foetus will 
be nearer the median line than in left positions. And thus we find it in 
practice. In right anterior positions the fetal heart sounds will be heard 
most plainly at about the same height as in left positions but much nearer 
the median line. 

In posterior positions, the heart sounds will be found about twice as 
far from the median line as in anterior positions. If in these cases the 
head is above the pelvic brim they will be heard far around in the flank. 
If the head has become engaged they will be heard four to six inches 
from the median line. 

Of course these rules are subject to many variations, but they are 
sufficiently exact to be of much practical value. 

It is evident that whatever causes the foetus as a whole to occupy a 
higher level will have the same effect upon the fetal heart. Thus, in a case 
of marked pelvic contraction, the heart sounds will be heard at a higher 
level than usual, and when the head has descended into the pelvic cavity, 
as it does in a primipara in the latter weeks of pregnancy, they will be 
heard at a lower level. It is an ancient fiction of the text-books that the 
heart sounds are heard above the umbilicus in breech presentations, but 
there are so many exceptions to this rule that it is best to disregard it. 
During the second stage of labor, when the head is on the pelvic floor, the 
heart sounds are heard not far from the symphysis ; a fact too often 
forgotten. 

During the fifth and sixth months, one should seek for the heart 
sounds in the median line below the umbilicus. He will often seek in 
vain. At this time, however, the viability of the child is not in question, 
and aside from the question of the diagnosis of pregnancy, the matter is 
of no great practical importance. 

But the fetal heart is not the only sound that we must learn to recognize. 
There are also the uterine, and the fetal souffles already mentioned. The 
former is in itself of no great diagnostic importance, but the latter may 
be of great value. In the absence of the fetal heart sounds the presence 
of the fetal souffle may be regarded as their equivalent. 

Internal Examination. — There is little danger of infection from 
vaginal examination during pregnancy, but it is always well to wash the 
hands thoroughly Avith soap and water, to wear sterile rubber gloves, and 
to immerse the gloved hand in lysol solution. All this is especially impor- 
tant if the examination is toward the end of pregnancy, when it is certain 
that labor cannot be far away. Now and then in the course of an ante- 



THE ANTEPARTUM EXA^IINATION 83 

partum examination one finds the patient in the first stage of labor, though 
the existence of labor has not been previously suspected. 

^Moreover, refined and sensitive patients always appreciate precautions 
of this kind. The rubber glove not only protects both patient and phys- 
ician from infection, but, when lubricated with lysol, renders the intro- 
duction of the fingers much easier and much less disagreeable to the 
patient. 

The examiner should note the condition of the vagina and its outlet 
with reference to size and distensibility, and should note the condition 
of the cervix. Bad cervical tears often indicate that the patient has had 
difiicult operative dehveries, and the reason for this should be sought. The 
fingers, however, should not be passed within the cervical canal without 
good reason. This involves too much risk of infection. Tumors large 
enough to obstruct delivery can hardly escape attention. 

Of course the most important part of the internal examination is the 
estimation of the internal pelvic measurements and particularly of the 
true conjugate diameter. But there are many cases in which we know 
in advance that these measurements are sufficient. For example, if there 
is a history of easy labors, ending in the delivery of children of good size, 
we may exclude pelvic contraction. Again, if, in the case of a primipara, 
the examining finger encounters the head almost at the vaginal outlet, 
it is plainly unnecessary to search for contraction at the brim. The 
measurement of the pelvic outlet, zvJiich should never he omitted, is part 
of the external examination. 

If, however, the patient has a history of difficult labor, or if, in the case 
of a primipara the head remains above the brim during the latter weeks 
of pregnancy, or if there is anything in the patient's history or appearance 
that suggests pelvic abnormality, the examination should be careful and 
thorough. The technic of pelvimetry, and the general subject of the 
diagnosis of pelvic contraction, are considered with the latter subject. 

Of course the antepartum examination will be valuable or not accord- 
ing to the experience and skill of the man who makes it. Its importance, 
however, should stimulate every man who intends to practice obstetrics 
to master the physical diagnosis of pregnancy. It is not a subject of 
extreme difficulty and what it reveals is of the greatest possible importance. 

Then, too, this systematic mapping out of the fetal parts, and measur- 
ing of the pelvis, are of great value to the physician. If he will but study 
each case, as it comes before him, following the methods here outlined, 
remembering that he can discover more by a very light touch than by rough 
manipulations, and that he should palpate with the tips of the fingers, 
not with the palms of his hands, the results will amply reward him. 



CHAPTER V 

THE FCETUS IN UTERO. CLASSIFICATION OF ITS DIF- 
FERENT POSITIONS AND PRESENTATIONS 

Before we can intelligently discuss the physiology of labor, or make 
any pretensions to a knowledge of obstetric diagnosis, we must know the 
topography of the foetus, and its immediate surroundings. 

Here, as elsewhere, we must first learn the technical vocabulary of 
the subject. It is necessary to fix in our minds, at the outset, the meaning 
of three terms which have become imbedded in the obstetric literature of 
€very modern language. z'i.c., attitude, position, and presentation. 

Attitude. — By this term is meant the manner in which the different 
parts of the foetus are disposed in relation to each other. The normal 
attitude of the foetus can be better illustrated than described. It is well 
shown in the accompanying illustration (Fig. 52) . The reader will observe 
how the head is flexed upon the chest, the arms folded, the legs flexed 
upon the thighs, and the thighs upon the body. King has aptly compared 
this position to that of one who is trying to keep warm in bed upon a cold 
night. It is a matter of every-day observation that the foetus retains this 
attitude, or something resembling it. for hours or even days after birth. 
\\'hat is the reason for this attitude? At first thought it would seem that 
it is the result of the accommodation of the foetus to the limited space 
which is reserved for it. This is undoubtedly true, so far as it relates 
to the latter months of pregnancy, and is especially evident in cases in 
which there is very little liquor amnii. and the foetus is exposed to unusual 
pressure. Here the foetus becomes a veritable mould of the uterine cavity. 

That there must be some other cause for this attitude, however, is 
shown by the fact that it is assumed early in pregnancy, when the foetus 
is simply floating in the amniotic fluid, and there can be no question of 
compression. 

Various theories have been advanced, but none are satisfactory. What- 
ever the cause, the object which nature has in view is plain. The foetus 
in this, its typical attitude, forms a comparatively symmetrical ovoid, 
taking up less room than it would otherwise occupy. ^Moreover the v\diole 
foetus constitutes, for the time being, a compact body, through which the 
propelling forces can be eft'ectively transmitted. This is especially true 
after the rupture of the membranes. 

Position. — The term position is used in two senses. The beginner 
will avoid confusion by learning to distinguish them before going further. 

The primary meaning of the term " position " is the relation of the 
foetus as a whole to the long axis of the uterus. Using the term in this 
sense, there are three positions— longitudinal, transverse and oblique. 
84 



THE FOETUS IN UTERO 



85 




86 



PREGNANCY, LABOR AND THE PUERPERIUM 



When the long axis of the foetus corresponds to that of the uterus 
the position is longitudinal. There can, of course, be only two longitudinal 
positions, according to which end of the fetal ovoid presents, the head or 
the breech. The terms transverse and oblique explain themselves. Strictly 
speaking, a true transverse position, as an obstetrical complication, is rare. 
Such a position, however, may occur if the foetus is small and the amount 




Fig. 53. — Mechanism of uterine contractions in transverse position of foetus. 



of liquor amnii large. I\Iost so-called transverse positions are really 
oblique positions, the shoulder being the presenting part. 

One often hears the phrase, '' transverse presentation," used as synony- 
mous with transverse position, but the term should be discarded not only 
because it is bad English, but because it serves to confuse the student. 

The second meaning of the term position is the relation of the pre- 
senting part to the birth canal or some one of its parts. Thus we may 
say of the head as a whole that it is above or below the brim ; or of the 
occiput, that it is anterior or posterior, to the right or to the left. 



THE FCETUS IN UTERO 87 

During the first half of pregnancy the foetus is relatively small, and 
ma}- occupy almost any position, but in the latter months it usually becomes 
longitudinal, and remains in this position. Transverse and oblique 
positions, at term, are exceptional. 

What is the reason for this? 

The following explanation seems the most plausible. As the foetus 
increases in length, it finally reaches a point at which it cannot assume 
a transverse or oblique position without coming into contact with the 
uterine wall. This contact excites uterine contractions, and the subjoined 
illustration shows clearly how these contractions, by directing the head 
and breech in opposite directions, cause the foetus to assume a longitudinal 
position, and tend to maintain it in this position (Eig. 53). 

Presentation. — The term presentation is best defined by illustration. 
\A'hen we speak of the presenting part of the foetus, we mean that part 
which has descended farthest in the pelvis, and which is most easily reached 
by the examining finger. The presentation is named after the presenting 
part. The term may be used in a general or a specific way, e.g., we speak 
of a head presentation in contradistinction to one of the breech. But 
head presentations may be subdivided into those of the occiput, brow, 
and face, and even these may be again subdivided, as we shall see directly. 
Again in a vertex presentation, or presentation of the top of the head, 
the occiput may point either forward or backward, to the right or to the 
left, and we may have a left occiput anterior presentation, a right occiput 
posterior, etc. 

Classifications of the Various Presentations. — Various schemes 
of classification have been devised. The Germans name the presentations 
first, second, third, etc. This is objectionable, as employing arbitrary 
symbols, instead of giving names that describe something and compel 
recollection. 

As we have already seen, the great majority of all presentations are 
those of the occiput. The reason for this we will consider later. At 
present we have to do only with the fact. 

These occipital presentations are divided into four classes, according 
to whether the occiput points anteriorly, or posteriorly, to the right, or to 
the left. Thus the most common, that in which the occiput points forward 
and to the left, is called the left occipito anterior, or L. O. A., and the 
presentation second in frequency, in which the occiput is directed pos- 
teriorly and to the right, is called the R. O. P. presentation. In both cases 
the head occupies the right oblique diameter of the pelvis, i.e., the oblique 
diameter which begins at the right sacro-iliac synchondrosis. \Vhen the 
head occupies the left oblique diameter, we have the R. O. A. and the 
L. O. P., positions much less frequent, as we shall see. In Figs. 54 to 69 
these positions are diagrammatically represented. 

Of course one can imagine any number of intermediate presentations. 
The older writers, with their love of detail, had hundreds of them. Even 



88 PREGNANCY, LABOR AND THE PUERPERIUM 

now, some include anteroposterior cases, i.e., cases in which the occiput 
is directly behind the symphysis. These, however, when they do occur. 



Fig. 54. 



Fig. 55. 





Fig. 56. 



Fig. 57. 





Positions of occiput in order of frequency. (After A. F. A. King, M.D.) 

are to be regarded as distinctly pathological, since, with a head of average 
size, delivery in this position is difficult or impossible. 

Since the vertex often presents transversely above the brim and in. 



THE FCETUS IN UTERO 



89 



other cases, especially in multiparcT, does not rotate until it has reached 
the floor of the pelvis, many writers use the term left occiput transverse, 




Fig. 59. 



Fig. 6o. 





Fig. 6] 




Positions of face presentation. (After A. F. A. King, M.D.) 

L. O. T., and right occiput transverse, R. O. T. ; for this there is more 
justification, but after all a transverse position of the vertex is merely a 
stage of rotation, and must eventually become either anterior or posterior. 



90 



PREGXAXCY. LABOR AXD THE PUERPERIU:\I 



The reader must have noticed, by this time, that presentations of the 
cephaHc extremity embrace the great majority of all presentations and that 



Fig. 62. 



Fig. 63. 





Position of breech presentation. (After A. F. A. King, M.D.) 

the head usually occupies the left oblique diameter; in other words that it 
is usually in the L. O. A. or the R. O. P. position. 

Two questions naturally arise here, ^^^hy does the head usually present, 



THE FCETUS IN UTERO 



91 



and why, when it does present, does it usually occupy the right oblique 
diameter ? 

AMiy are cephalic presentations the rule, and other presentations the 
exception ? 

Fig. 66. Fig. 67. 




Fig. 68. 



Fig. 69. 




Position of shoulder presentation. (After A. F. A. King, M.D.) 



The position of the head has been attributed to gravitation. The head 
sinks to the bottom of the amniotic pool, it is said, because it is the heaviest 
part of the foetus. This theory might conceivably apply to the latter part 
of pregnancy, but not to the earlier part when the head is relatively small. 



92 PREGNANCY, LABOR AND THE PUERPERIUM 

According to another theory, the position of the head is the result 
of a process of accommodation ; the head fits best into the lower uterine 
segment. When it is located elsewhere the foetus is uncomfortable and 
reflex movements are excited. Neither of these theories is very satisfac- 
tory. Bumm has made the shrewd observation that once the head has 
settled into the lower uterine segment, its size and weight make its dis- 
lodgement a difficult task for the foetus. This of course applies only to 
the latter months of gestation. 

Why does the fetal head, in the great majority of cases, occupy the 
right oblique diameter of the pelvis ? In other words, why do the L. O. A. 
and R. O. P. presentations comprise the vast majority of all presentations? 
The most plausible explanation is that already given for the common right 
obliquity of the uterus, vis., the position of the rectum and sigmoid 
flexure. 

Another question must by this time have occurred to the reader. Why 
does the occiput usually point forward? Or in other words, what is the 
reason for the preponderance of the left anterior position? 

As a matter of fact, it is not as much more frequent than the posterior 
positions as it is usually supposed to be. As noted in the above diagram, 
the occiput is originally posterior and to the right in about one-third of 
all cases. The fact that it usually rotates during labor and is delivered 
in an anterior position, leads those who do not practise the external 
examination of pregnancy to believe that it is much less frequent than is 
really the case. 

Nevertheless, the fact remains that anterior positions are at least twice 
as common as posterior ones. The most reasonable explanation seems to 
be, that this is the result of accommodation between the foetus and the 
structures anterior and posterior to the uterus ; the concave abdominal 
surface of the child, adapting itself more readily to the outward curve 
of the lumbar spine. 

Figs. 54, 55, 56 and 57 show the principal varieties of occiput presen- 
tation, as usually observed in multiparse. As we shall see in studying the 
mechanism of labor, the head occupies an altogether different position 
in primiparse who are near term. During the latter weeks of pregnancy, 
the head, in the case of a multipara, is normally above the brim and only 
moderately flexed, while in the case of a primipara, it is well down in the 
pelvic cavity, and well flexed. The student should fix this fact firmly in 
his mind, for without it he cannot intelligently practise the antepartum 
examination, or study the mechanism of labor. 

But the occiput is not always the index of classification. In face 
presentations, to be discussed later, it is the chin (Latin, mentum). Thus 
we have the left mento anterior, or L. M. A. position, etc. These are 
shown in Figs. 58, 59, 60 and 61. In breech presentations the index is the 
sacrum and we have the left sacro anterior, etc., as shown in Figs. 62, 6^, 



THE FCETUS IN UTERO 93 

64 and 6^. In shoulder presentations the index is the scapula and we have 
the left scapula anterior, etc. (Figs. 66, 67, 68 and 69). 

To sum up then there are two principal positions of the foetus in utero^ 
longitudinal and transverse, the latter including oblique positions, which 
indeed constitute the great majority of this class of cases. 

There are four principal presentations, those of the occiput, face, 
breech, and shoulder, subdivided as follows : 

Presentations of the occiput : L. O. A., R. O. A., R. O. P., L. O. P. 

Presentations of the face: L. M. A., R. M. A., R. M. P., L. M. P. 

Presentations of the breech : L. S. A., R. S. A., R. S. P., L. S. P. 

Presentations of the shoulder: L. Sc. A., R. Sc. A., R. Sc. P., L. Sc. P. 

This list might be further extended, but for the sake of simplicity and 
clearness it is better to leave it as it is. Presentations of the foot and 
knee are to be regarded as modifications of breech presentations, those 
of the hand as modifications of presentations of the shoulder. A brow 
presentation is really an incomplete face presentation. Compound presen- 
tations, i.e., the simultaneous presentation of two or more parts, a hand 
and a head, a foot and a head, etc., defy classification. Presentations of 
the abdomen and back are obstetric curiosities and can only occur when the 
foetus occupies a transverse position. Descent of the cord is sometimes 
called presentation of the cord, but this, of course, is not a presentation 
at all, but a prolapse. 



CHAPTER VI 

THE PHYSIOLOGY AND MECHANISM OF LABOR 

Ix the term labor are included those phenomena which accompany 
the expulsion of the foetus and its appendages. In order that we may 
discuss the subject intelligently, it is necessary to consider with some care 
the fetal head, the chief obstacle to delivery, and the canal through which 
it must pass ; or to use the quaint but expressive phraseology of the older 
writers, the passage and the passenger. Having done this we will be in a 
position to consider the forces by which delivery is accomplished and the 
mechanism necessary for its completion. 

The Birth Canal 

The termx birth canal, a comprehensive and useful, if not elegant, one, 
is employed to designate the channel through which the foetus must pass 
on its way to a new existence. This channel is formed by the bony pelvis, 
and the soft parts which line its cavity and close its outlet. A general 
knowledge of these structures is presupposed and reference will be made 
here only to certain features which require special attention. 

The Pelvis. — Let us look first at the normal female pelvis, and see how 
it differs from that of the male. It is evident that all these differences 
are designed to make the process of labor easier than it otherwise would be. 

Let us then look at the pelvis of infancy and note that changes, 
obviously for the same purpose, occur as the child grows into womanhood. 

A knowledge of these difTerences will help us when we come to the 
study of pelvic contraction, for we will then see how this contraction is 
often due to a persistence of the infantile type of pelvis, or of an approxi- 
mation of the female pelvis to the masculine type (Figs. 70, 71, 72 and 73). 

First of all the student should learn well the form and dimensions 
of the normal female pelvis, and the axis of its canal. It is convenient 
and perhaps necessary to recall the planes of the brim and outlet, but 
for practical purposes this is all that is necessary. 

Attempts to simplify the matter by geometrical puzzles have only 
served to make tiresome and difficult a subject that is, in its essentials, 
not difficult of comprehension, with the result that the student regards it 
with horror, and forgets it as soon as possible, while the practitioner does 
not read it at all. It is of course possible to construct or imagine an 
infinite number of planes in the pelvic cavity, but the result is confusion 
rather than enlightenment. Some writers speak of the internal lateral 
surfaces of the pelvis as the inclined planes of the pelvis. This serves 
only to add to the confusion of the student. Of course these so-called 
inclined planes are not planes at all, in the mathematical sense of the word. 
94 



PHYSIOLOGY AND AIECHANISM OF LABOR 95 

They were formerly considered of great importance, as effecting the 
forward rotation of the occiput, but, as we shall see presently, their 
intiuence in this respect is theoretical rather than practical. 

Taking up now the normal female pelvis, we see at once that it is com- 
posed of the two innominate bones together with the sacrum and coccyx, 
and that it is divided by a natural line of division into two parts. These 
parts are called the true and the false pelvis, and the line of division 
is our old friend of student days, the linea iliopectinea. 

The False Pelvis. — The false pelvis, the upper part, interests us 




Fig. 70. — Normal female pelvis viewed from above. Boundary and diameters of inlet drawn in. 

principally from the standpoint of diagnosis. Of course it offers no 
resistance to the progress of labor, but as we shall see later it does off'er 
certain landmarks for the practice of pelvimetry or pelvic measurement, 
and by its shape and inclination aids us in estimating the character of 
the true pelvis, and in diagnosing certain forms of pelvic deformity. 

The True Pelvis. — The true pelvis is full of practical interest. It 
falls naturally into three divisions, brim, cavity, and outlet. 

The Pelvic Brim. — The pelvic brim, inlet, or superior strait, as It is 
variously called, is bounded in front by the symphysis pubis, behind by the 
promontory and alse of the sacrum, and on each side bv the linea ilio- 



96 



PREGNANCY, LABOR AND THE PUERPERIUM 



pectinea. In the erect posture the plane of the brim makes an angle of 
55 to 60 degrees with the horizon. The inclination of the brim is, how- 
ever, a very variable quantity changing with the position of the patient. 
More important are the diameters of the brim, for a slight diminution in 
size of this bony barrier to the progress of labor may result in disaster. 

These so-called " diameters " are simply the average distances between 
certain fixed points. The reader will note as he proceeds that like the 
" planes " mentioned above they are not diameters at all in the mathematical 
sense. 

The diameters of the brim are, the anteroposterior or conjugate 
diameter, the transverse diameter, and the right and left oblique diameters. 

Most important of all is the anteroposterior, for it is the shortest 
diameter of the brim, and moreover anteroposterior contraction at the brim 



V 


9 




/ M 

A 11 




V 


;tflL 


i 





Fig. 71. — Normal pelvis viewed from below. Boundary and diameters drawn in. 

is the most common form of pelvic contraction. This diameter is drawn 
from the promontory of the sacrum to the middle of the top of the 
symphysis and measures 11 centimetres. Strictly speaking, this is some- 
times called the anatomical rather than the obstetrical conjugate, since the 
posterior surface of the symphysis curves in slightly from the top and 
the point nearest the sacrum is a little below the top of the symphysis. 
It is from this point that the true obstetrical conjugate is taken, or would 
be taken if possible. It measures 10.5 centimetres. 

The transverse diameter of the brim at its widest part measures 13 
centimetres. 

The right and left oblique diameters are taken, the former from the 
right and the latter from the left sacro-iliac synchondrosis, each extending 
to the iliopectineal eminence of the opposite side. 

The Pelvic Outlet. — Although the cavity comes next in chronological 
order. It is best first to describe the outlet, since we can only define the 



PHYSIOLOGY AND MECHANISM OF LABOR 



97 



cavity as the space between the mlet and outlet. It is bounded by the 
pubic arch in front, the tuberosities of the ischia below, and the spines 
of the ischia behind. It has two principal diameters, the anteroposterior, 
from the middle of the subpubic arch to the tip of the coccyx, 9.5 centi- 
metres which, however, is increased to 11.5 centimetres when the coccyx 
is bent backward, and the transverse, which is taken from one ischial 
tuberosity to the other, and measures 11 centimetres. 

It must be admitted that, as we view the bony skeleton, what is called 
the pelvic outlet does not look like an outlet at all. It is necessary to 
reconstruct, in imagination, the birth canal, by " filling in " the soft parts. 
These soft tissues, made up 
chiefly of the levator ani muscle, 
complete the lower segment of 
the birth canal and help to consti- 
tute its true outlet. It is only in 
certain cases of pelvic contraction 
that the so-called outlet is really 
an outlet in the ordinary sense of 
the term. The reader will note 
also that it is almost round, and 
that, contrary to the opinion for- 
merly held, there is little differ- 
ence between its anteroposterior 
and transverse diameters. 

The Pelvic Cavity. — The pel- 
\\c cavity is the space between 
the inlet above, the outlet below, 
and the anterior, posterior, and 
lateral walls of the pelvis. Of 
course, if we disregard the soft 
parts, it is not really a cavity ; but 
there is no other word that will 
take its place. Anything, usually 
of course, the fetal head, that is 
between the inlet and the outlet is said to be in the cavity. In normal cases 
the anteroposterior diameter of the pelvic cavity, i.e., the distance from the 
middle of the posterior surface of the symphysis to the middle of the 
concavity of the sacrum is 12 centimetres, while its transverse diameter 
taken from one ischial spine to the other is 10.5 centimetres. 

When we recall that the plane of the inlet looks downward and back- 
ward and that of the outlet upward and forward it becomes obvious that the 
pelvic canal, and still more the 'birth canal, in which the soft structures are 
added, must be a curved canal. But it is not a symmetrically curved canal, 
like the traditional one of Carus. In other words, its axis is not a segment 
of a circle. As is well shown in Fig. 74, the axis of the superior strait is 
7 




Fig. 72. — Sagittal section of normal pelvis. 



PHYSIOLOGY AND MECHANISM OF LABOR 99 

practically a straight line until, or almost until, it meets the plane of the 
outlet. This is proven clinically, as I have often remarked in using the 
Tarnier forceps, by the fact that traction is almost in a straight line until 
the head has reached, or almost reached, the floor of the pelvis. The 
correct line of the pelvic axis was realized by Hodge many years ago, but 
his ideas have been slow in flnding acceptance. 

The matter is obviously one of great practical importance. For 
example, if we really believed that the pelvic axis corresponds to the 
traditional curve, and in the course of a forceps operation should raise 
the handles of the forceps long before the head had reached the pelvic 
floor, we would never succeed in accomplishing delivery at all. 

The Soft Parts. — AMiat have the soft parts to do with the pelvic 
canal ? \>ry little except at the outlet, and here a great deal. In primiparae 




Fig. 74. — Diagram showing pelvic axis. (After Williams.) 

the head is low in the pelvis long before labor begins and if no outlet 
exists, the second stage, much longer than in multiparae, is entirely devoted 
to overcoming the resistance of the soft parts. How this resistance is 
overcome we will consider directly. 

It is a matter of clinical observation that, other things being equal, 
labor is more difficult in very stout women and perhaps in those of great 
muscular development, e.g., in athletes, but even in these cases the difficulty 
is chiefly at the outlet. 

The ]\Iasculine Pelvis. — What are the principal points of difference 
between the male and the female pelvis? 

In the male the pubic arch is much longer and narrower. The trans- 
verse diameter of the brim is diminished and Its shape Is round, rather 
than oval. The pelvis as a whole Is deeper and more funnel-shaped and 
the measurements of the outlet are much smaller. 



100 PREGNANCY, LABOR AND THE PUERPERIUM 

The Pelvis of Infancy. — In the new-born the vertebral column 
forms, with the sacrum and coccyx, what is approximately a straight line. 
The promontory is much higher, its width less, its lumbosacral portion 
much less convex, and not encroaching upon the pelvic cavity, while its 
pelvic inclination is from seventy-five to eighty degrees, as compared with 
fifty-five to sixty degrees in the adult female. The sacrum is flat trans- 
versely, instead of concave as in the adult, and is relatively small. The 
whole pelvis is relatively smaller and approximates the funnel type and 
the iliac tuberosities are nearer each other than the spines, the reverse 
being the case in the adult. The iliac bones are relatively much smaller 
and form, with the iliopectineal line, an angle of one hundred and fifty-five 
degrees, as opposed to one of one hundred and twenty-five degrees in 
the adult. 

Divergence of type may be recognized in the fetal pelvis as early as the 
fourth or fifth month of intra-uterine life ; and yet the characteristics of the 
female pelvis in the new-born are still predominantly masculine. The 
subsequent changes which are necessary to convert the pelvis into the 
true feminine type continue through childhood, and, as we shall see later, 
are apparently the result of the everyday occupations, pursuits, and 
exercises of child life. 

Speculation as to the cause of the differences between the male and the 
female pelvis has thus far been futile. It is easy to explain why the pelvis 
of childhood should undergo certain changes as the result of standing, 
walking, sitting, etc., changes which will be discussed when we come to 
study pelvic contraction, but why these changes should differ with the 
sex of 'the individual is one of those riddles of organic life which, in the 
present state of our knowledge, defies solution. 

The Pelvic Joints. — The pelvic joints are not immovable synchon- 
droses but joints in the true sense of the word. At least this has been 
proven by Luschka in the case of the sacro-iliac articulations, while Budin 
showed long ago that there is considerable motion at the symphysis during 
the latter part of pregnancy. This he did by introducing his finger into 
the vagina and causing the patient to walk, thus recognizing the up-and- 
down movements of the pubic bones upon each other (Fig. 75). 

The movement at the sacro-iliac joints has been demonstrated by 
'Walcher's employment of the Hdngelage, or hanging position, in which 
the patient is brought to the edge of the table, the ischial tuberosities 
resting upon its edge, the legs and thighs hanging over. The weight of the 
latter drags the symphysis directly downward and the rotation of the 
innominate bones upon the sacrum increases its distance from the sacrum 
by about one centimetre, as shown in the accompanying diagram. Of 
course this could only be the result of the rotation of the ossa innominata 
upon the sacrum. Of the Walcher position I shall speak again in 
connection with the subject of contracted pelvis (Fig. y6). 

The Fetal Head. — As we have already seen the fetal head is relatively 



PHYSIOLOGY AND MECHANISM OF LABOR 



101 



very large. It presents a greater bulk than any other part of the foetus, 
and is consequently the greatest obstacle to delivery. 

The pelvis must be traversed by the fetal head. Neither the fetal head 
nor the pelvic cavity is symmetrical. The process is one of accommo- 
dation. It is necessary for us to acquaint ourselves with the size and 
shape of the fetal head and with the length of its various diameters, since 




Fig. 75- — Change in length of conjugate diameter upon maximum stretching of pelvis. 



it is plain that only by the adaptation of its smallest diameters to the 
largest diameters of the pelvic canal can the best results be obtained. 

The fetal head is divided into the cranium and the face. The cranium 
is again divided into the vault and the base, the whole forming an irregular 
ovoid (Fig. ']']'). Note the small size of the face in proportion to the 
cranium. Note also that, in man, the cranium is much larger than in any 
other of the higher mammals, an honor for which the penalty must be 
paid in difficult labor. 



102 



PREGNANCY, LABOR AND THE PUERPERIUM 




Fortunately for the mother, the fetal head is not covered by a compact 
and solid bony layer as is that of the adult. The different bones that 
compose the skull have not yet been welded into one. They are still, 
as in the prenatal state, soft and malleable, and are still separated from 
each other by fibrous connections. Between the bones run lines of division 
which can be both seen and felt, and which permit an overlapping of the 
bones, and a consequent reduction of the size of the head. These are the 
sutures. At the junctures of the sutures are the fontanelles. The sutures 

are bands of fibrous union, the fon- 
tanelles are fibrous apertures at the 
union of three or more sutures. 

The Sutures and Fontanelles. 
— The sutures that interest us are the 
following : 

The sagittal suture between the 
two parietal bones. 

The frontal suture, between the 
two, as yet, ununited halves of the 
frontal bone. 

The coronal suture, between the 
frontal and parietal bones on each 
side. 

The lamboid suture, between the 

occipital bone and the two parietals. 

The fontanelles are six in number : 

The anterior or large fontanelle, 

also called the parietofrontal. 

The posterior, or small fontanelle. 
The lateral fontanelles, two on 
each side, otherwise known as the 
pterion and theasterion,or the antero- 
lateral and posterolateral fontanelles. 
The anterior fontanelle is formed 
by the junction of the sagittal, frontal, 
and two coronal sutures. It is a 
land-mark of great diagnostic importance. It is distinguished by the 
fact that from it radiate four sutures, that it is large and soft, and that 
it is never closed, even when the head is compressed during the progress 
of labor. 

The posterior, or small fontanelle, is formed by the junction of three 
lines of sutures, the sagittal and the two branches of the V-shaped lamboidal 
suture. During labor, after the memibranes have ruptured and the head 
is subjected to pressure, there is really no fontanelle in this location, but 
rather a triangular depression indicating the pushing of the occipital under 
the two parietal bones. On each side of this depression is a ridge, marking 





Fig. 76. — Walcher's position. 



PHYSIOLOGY AXD MECHANISM OF LABOR 



103 



one lateral half of the lamboidal suture, while from the intersection of 
these ridges can be traced the sagittal suture. 

The anterolateral fontanelle at the end of the frontal suture is too 




deeply situated for recognition and is therefore of no clinical importance. 
The posterolateral, however, at the junction of the temporal, occipital, 
and parietal bones, may by reason of its three diverging sutures be mistaken 
for the posterior fontanelle. 



104 PREGNANCY, LABOR AND THE PUERPERIUM 

The dimensions of the fetal head are usually expressed in what are 
called " diameters," though as the reader will note, they are not diameters 
in the strict sense of the word since they do not pass through the centre 
of the head. 

The following are the diameters which we need to remember, with the 
approximate length of each. 




Fig. 78. — Fetal head, from above. Actual size. A-Ai,biparietal diameter; B-B^, bitemporal diameter. 



The occipitofrontal diameter or the greatest distance between the 
forehead and the occiput, 12 centimetres. 

The biparietal or the greatest distance between the parietal eminences, 
9^ centimetres. 

The bitemporal diameter or the greatest distance between the lower 
ends of the coronal suture, 8 centimetres. 

The occipitomental diameter, 1314 centimetres. 



PHYSIOLOGY AND MECHANISM OF LABOR 



105 



The siiboccipito bregmatic diameter, from the base of the occiput to 
the anterior fontanelle, 9^2 centimetres (Fig. 79). 

It is more important to recall the relative length of the various diame- 
ters than the exact length of each one. To know, for example, that the 
suboccipito bregmatic diameter, which is the diameter of engagement when 
the head is well flexed, is considerably shorter than the fronto-occipital, 
which presents when the head is not flexed at all, not only helps one to 
understand the mechanism of labor but suggests a rational treatment 
(Figs. 80 and 81). 

It is customary to construct in the imagination certain planes corre- 
sponding to the various diameters. Thus we have the suboccipito breg- 




FiG. 79- — Fetal head, from behind. Actual size. A-A^, biparietal diameter. 



matic plane, the smallest of the planes that are likely to engage in some 
part of the birth canal, the one which does engage in normal delivery, and 
various other planes of larger diameters whose engagement is less favor- 
able. It is hardly necessary, however, to multiply the number of these 
planes as was formerly customary and is still done by some writers. To 
miy mind it is unwise to introduce any more mathematics into the subject 
than is absolutely essential. If a diameter is large, the corresponding plane 
is also large, and it hardly seems necessary to support this obvious fact 
by geometrical demonstrations. 

The loose, fibrous union of the bones of the fetal skull is of great 
practical advantage in that it permits overlapping of the bones, and with 



106 PREGNANCY, LABOR AND THE PUERPERIUM 

a resulting diminution in the size of the head and particularly of the 
presenting part. As we shall see later, this is especially marked in cases 
of pelvic contraction. Some little overlapping of the occipital bone by the 
parietals often occurs in normal labor. 

Overlapping of the bones, however, is not the only factor that serves 
to diminish the size of the presenting part. So malleable are the bones 
of the fetal skull, owing to the fact that they are not as yet completely 
ossified, that during labor they become configured or moulded to fit the 
canal through which they must pass. This moulding is noticeable in all 



!f 



/ 





■^ .^^ 



c 






9.6 cm. 
ffjScm' 



Figs. 80-81. — Diagram showing effect of flexion, conversion of occipitofrontal into suboccipito breg- 
matic diameter. (After Williams.) 

vertex presentations unless labor is very easy. It is, of course, absent 
in cases of breech delivery and of Caesarean section. 

The size and compressibility of the head vary widely with the age of 
the foetus. This is a fact seldom emphasized but of the greatest impor- 
tance. The head of the premature foetus is not only much smaller but 
much softer and more compressible than that of the foetus at term. On 
the other hand, when pregnancy is prolonged beyond its usual limit, the 
head is often found to be not only much larger than usual but also much 
less compressible. During the latter part of pregnancy the head grows 
by leaps and bounds, not only in size but in hardness, and the skull becomes 
not only much larger but much harder. The fontanelles become smaller, 



PHYSIOLOGY AND MECHANISM OF LABOR 107 

the sutures narrower, overlapping of the bones is Hmited, and moulding 
much less easy. This accounts for the great difficulty in delivery some- 
times experienced when the patient has " gone over her time." 

The Physiology of Labor 

Just as the contents of any hollow viscus are expelled by muscular 
contraction so are those of the uterus. The muscles that are brought 
into play are first and most essentially those of the uterus. These muscles 
are beyond the control of the patient. She has no power to initiate or 
continue their contraction. They are indispensable to the beginning or 
the continuance of labor. They act mostly during the first stage but 
may act at any stage. Their chief function is to bring about dilatation 
of the cervix. 

But the analogy does not end here. Just as the emptying of the 
rectum or bladder may be aided by the contraction of the abdominal 
muscles, so may the emptying of the uterus. In either case the muscles 
are those of the diaphragm and the abdominal wall. They are to a large 
extent under the control of the patient. Their action is highly important 
but not absolutely indispensable, They act only during the second stage 
of labor and their chief function is the propulsion of the foetus. 

The role then that is played by the involuntary muscles is by far the 
most important. It continues, or may continue, during the whole course 
of labor. \\'ithout it the process would never be naturally completed. 

The role of the voluntary muscles, though often of great importance, 
is a minor one. It is not absolutely necessary to the completion of labor. 

THE CAUSE OF LABOR 

The expulsion of the uterine contents then is the result of muscular 
contractions. But such contractions have been going on since the begin- 
ning of pregnancy and are easily demonstrated during the latter months. 
Why have they not resulted in the expulsion of the foetus at an earlier 
period of pregnancy? In other words, What is the cause of labor? 

The student need not fear that he will be asked this question upon 
examination. The examiner himself does not know. 

Since the dawn of medical history there has been much speculation 
upon this point. Hippocrates believed that the child is driven from 
its uterine shelter by the pangs of hunger. Many theories advanced since 
that time have had little more probability. 

The onset of labor has been attributed to the periodical congestion 
which attends the menstrual epoch and which is thought to continue 
throughout pregnancy, occurring at those periods when the patient would 
menstruate if she were not pregnant. The ordinary date of labor is taken 
to correspond with the tenth menstrual period. 

Other causes that have been advanced are uterine distention, fatty 
degeneration of the decidua, pressure upon the cervical ganglia, excess 



108 



PREGNANCY, LABOR AND THE PUERPERIUM 



of carbon dioxide in the maternal blood, heredity, or more properly 
speaking, natural selection, and anaphylaxis, etc. . To discuss them all 
would serve no useful purpose here. 

Personally I do not believe that there is any distinct line of demar- 
cation between pregnancy and labor. The cervix is softened and in 
many cases considerably dilated by the painless contractions that go on 
during the latter weeks of pregnancy. As Bayer has aptly remarked, there 

Aortic plexus (thoracic) 

Phrenic nerve H Vagus nerve 

Splanchnic ner\ c ^ W \ Splanchnic nerve 

' 'tfc'' ^..-^ - Solar ganglion 



Superior renal ganglion 
Inferior renal ganglion 

Superior genital ganglia 



I Spermatic pi 




Lumbar ganglia 
(.sympathetic) 



Large uterine 
plexus 



Right hypogastric ^ 
plexus 



exus (ovarian nervesj 



Fig. 82. — Genital nervous system in the female. Innervation of the uterus. (After Frankenhauser.) 

is no difference between the contractions of pregnancy and those of labor, 
except that the latter are attended by pain. I have several times demon- 
strated, by vaginal examination, that there is tension of the amniotic 
sac during the contractions of pregnancy long before the beginning of 
true labor. 

If it be asked. Why does labor fall upon the two hundred and eightieth 
day of gestation? the reply is, that we have no means of knowing that it 
does. Ahlfeld's tables showed a variation of three weeks, and every 
practitioner knows how unreliable are the usual methods of estimating 
the duration of pregnancy. The fact that the duration of pregnancy is 
approximately ten lunar months does not seem to require any more 



PHYSIOLOGY AND MECHANISM OF LABOR 109 

explanation than that menstruation occurs every four weeks, or that 
puberty or the menopause corresponds to certain periods in the Hfe of 
woman. 

The Nervous Supply of the Uterus. — Of course uterine contractions, 
like other contractions, occur in response to nervous stimuli. Whence 
come the stimuli that cause the expulsion of the contents of the uterus? 

The familiar dissections of Frankenhauser, which have been copied 
into nearly every text-book, still afford the best illustrations of the ana- 
tomical conditions, and for these the student is referred to the accompany- 
ing beautiful reproduction from Bumm (Fig. 82). 

The nervous supply of the uterus is very complex, and many points 
in this connection are still unsettled. It is important to note the fact that 
the sympathetic system plays by far the most important part in the process 
of labor, and that, while motor impulses are transmitted to the uterus 
from the sympathetic system, sensory impulses come exclusively from the 
spinal cord. This is shown by the fact that when communication with 
the spinal cord is cut off, as in myelitis or paraplegia, labor is painless. 
It is also proven by the results of spinal anaesthesia and by experiments 
upon animals. Even when the spinal cord is completely severed labor 
may go on to a natural conclusion. This seems to show the existence of 
independent nerve centres, intrinsic uterine ganglia, which in some way 
as yet unknown give the first impulse to uterine contraction. 

The reader should not fail to remark the relatively enormous nerve 
supply of the cervix. Noting this, it is easy to understand the fact that 
dilatation of the cervix is the most powerful impulse to uterine contraction, 
and to account for the extreme suffering that characterizes the approach 
of complete cervical dilatation. 

It was formerly taught that there is in the medulla a special centre 
for uterine contractions but this has not been proven and is, antecedently, 
highly improbable. There can be no question, however, that the brain 
exercises, or may exercise, a regulating or inhibitory influence upon 
uterine action. Every nurse is familiar with the fact that the arrival 
of the physician sometimes " stops the pains " for a time, and every 
observant practitioner is familiar with the fact that, in the case of certain 
over-sensitive patients, the effect of fear is to inhibit uterine contraction 
and delay labor. 

But to return to more practical considerations. 

The uterine contractions are in the form of peristaltic waves beginning 
at the fundus and extending to the cervix. This has been definitely proven 
in the case of the lower animals, and reasoning from analogy is highly 
probable in man. The clinical history of these contractions will be con- 
sidered presently. It is the clinical history of labor. Let us here consider 
briefly the mechanism by which they effect their object. 

We must first recall the classical division of labor into three stages. 
The first stage lasts from the beginning of labor until complete dilatation 



no PREGNANCY, LABOR AND THE PUERPERIUM 

of the cervix has been attained. The second stage begins at this point 
and continues until the dehvery of the child. With the delivery of the 
placenta and membranes the third stage is complete. If we would discuss 
the subject intelligently we must consider each stage separately. 




Vein 



Artery 




THE DILATATION OF THE CERVIX 

The object of the contractions of the first 
stage is the dilatation of the cervix. How is 
this accomplished? 

We need not stop here to consider the essen- 
tial nature of a uterine contraction. Suffice 
it to say that it is a process of rearrangement 
of muscular fibres. 

Most men get the idea that the fundus con- 
tracts from side to side and thus '' squeezes " 
the fetal head through the cervix into the va- 
gina. This is an incorrect and mischievous idea 
that should be discarded at the outset. True the 
uterus does contract, but it also retracts, i.e., it 
shortens from fundus to the contraction ring. 

This retraction of the uterus during labor 
is a highly important phenomenon but its essen- 
tial nature is not well understood since it finds 




Fig. 83. — A, Arrangement of fibres in the gravid uterus; B, Rearrangement of the same in 

retracted uterus. 

no exact parallel in the behavior of other muscular organs. We need not 
wonder at this when we recall the fact that skilled and unwearying investi- 
gators have not been able fully to understand or describe the complex 
arrangement of the muscular fibres of the uterus. Suffice it to say, that it 
is a process of rearrangement of the fibres. This is well shown in the 



PHYSIOLOGY AND jNIECHANISM OF LABOR 



111 



accompanying illustration from Bumm. Fibres that were end to end at the 
beginning of the process are side by side when retraction is complete. 
From this it results that after the emptying of the uterus the thickness 
of the uterine wall has been enormously increased (Fig. 83). 



Ring of 
Bandl " 



Vagina— 





Fig. 84. ^Showing changes in uterus at the end of period of dilatation. 

What we need now is not to understand this process, but to remember 
it. The latter is absolutely necessary to any rational comprehension of the 
physiology of labor. 

When the uterus contracts it does not compress its contents equally 



112 PREGNANCY, LABOR AND THE PUERPERIUM 

and uniformly above, below, and on all sides. If this were the case all 
progress would soon cease and the uterus would be exhausted or ruptured 
by unavailing effort. There is a break in the continuity of the uterine 
cavity — the internal os. Into the circular fibres that constitute the bulk 
of the internal os are inserted the longitudinal fibres of the body of the 
uterus. These fibres exert an eccentric pull upon the os which gradually 
effects its dilatation and draws it up over the presenting part. The head 
is not pushed through the cervix. The ceri'iv is drazvn up over the head. 
With the retraction of the uterus the upper part becomes thicker, and 
with the ascent of the contraction ring the part below it becomes distended 
and thinned. 

Thus, toward the end of the first stage, the uterus becomes divided 




Internal os 
Cavity of cervix 

External os 



Fig. 85. — Cervix of a primipara at beginning of labor. 

into two parts : an upper, thick, contracting and retracting part, bounded 
below by the contraction ring, a muscular ring, especially prominent pos- 
teriorly; and below this a thinned and distended portion, the lower uterine 
segment and the cervix (Fig. 84). 

In primiparse the cervix is gradually flattened out from above down- 
wards, the internal os being first obliterated and then the external. In 
multiparse, however, the resistance of the external os has been overcome 
in previous labors, and the internal is the only obstacle interposed by the 
cervix. 

The '* Bag of Waters." — But uterine contraction is not the only factor 
in overcoming the resistance of the cervix. Another and a very important 
factor is the dilating pressure of the lower segment of the amniotic sac, 
the " bag of waters," as it is called in the quaint phraseology of the lying-in 



PHYSIOLOGY AXD ^lECHANISM OF LABOR 



113 



chamber. As soon as the cervix has dilated to any extent some of the 
amniotic fluid finds its way in front of the head, and the pouch thus 
formed is driven by each succeeding contraction into the resisting ring 
of the internal os, and becomes a powerful ally in the production of cervical 
dilatation. How necessary this hydrostatic dilatation of nature is to the 
progress of labor is shown by the fact that in cases of premature rupture 
of the membranes, or " dry labor," as it is called, with which we shall 
have to do later, much delay and difficulty are encountered (Fig. 87). 

'* The bag of waters " acts not only as a dilator, but by its mere 
presence in the cervix, as a reflex excitant of uterine contractions. We 
have already referred to the rich nervous supply of the cervix and, when 
we come to the study of obstetric surgery, we shall see how the mere 




Expanded portion 
of cervix 



External 



Fig. 



-Primipara. Period of dilatation. Upper half of cervix unfolded. 



presence of a rubber bag in the cervix is sufficient to excite uterine 
contraction and to usher in all the phenomena of labor. 

Normally the head fills the pelvic brim and acts as a ball valve to 
prevent the overfilling of the presenting pouch of membranes. \Mitn. 
however, this is not the case, e.g., in breech or shoulder presentation when 
the presenting part does not fill the brim, or in cases of contracted pelvis, 
when the brim is too small to admit the head, the fluid may escape past 
the head in large quantity, forming a long pouch like a great glove finger 
which projects, through the half dilated cervix, into the vagina. Indeed, 
this is an important diagnostic sign of pelvic contraction (Fig. 88). 

In rare instances the membranes do not rupture at all, and the child 
is born surrounded by the unruptured amniotic sac. According to tradi- 
tion, this is of favorable omen and augurs well for the future of the child. 
8 



114 PREGNANCY, LABOR AND THE PUERPERIUM 

The sac or '' caul," as it is popularly called, has been preserved in many 
a household. 

Not every discharge of fluid from the vagina, however, is a real 
'' rupture of the membranes." In some cases there is a collection of fluid 
between the amnion and the chorion, the Amnio chorialis IVasser of the 
Germans. Again, a watery discharge may be the result of the rupture of 
cysts that characterize certain forms of decidual endometritis. These 
two conditions serve to explain those cases in which we find the '' bag of 
waters " still preserved, in spite of the fact that a watery discharge has 
taken place. 

When complete dilatation of the cervix has been reached, the retraction 




Fig. 87. — Cylindrical bag of waters. 



of the uterus is, as a rule, also complete. The cervix cannot be stretched 
more and the round ligaments prevent the further ascent of the fundus. 
Hence all uterine pressure is exerted upon the foetus. The barrier of the 
cervix has been removed and there remains no obstacle to the progress 
of the head, which now for the first time begins to descend. In the case 
of a multipara the head which, up to this time, has been above the pelvic 
brim, begins to descend into the pelvic cavity. In the case of a primipara 
the head, already in the pelvic cavity, descends to the pelvic floor. 

But nature has set limits to the power of the uterine muscle. With 
the cervix fully dilated and the limit of retraction reached, something 



PHYSIOLOGY AND MECHANISM OF LABOR 



115 



else is needed to complete the parturient process. This is found In the 
contraction of the abdominal muscles. These are voluntary muscles and 
the patient is now able to help herself. Before this time bearing-down 
efforts have been useless or injurious. Now they are of service, and the 
more so as the head advances. But the contractions of the second stage 
are not entirely voluntary. As the head approaches the sensitive structures 
about the ostium vaginae, the reflex stimulus to " bear down " becomes 
almost or quite irresistible. Some women, however, manage to resist this 
impulse and to delay labor for a long time. 

\\'ith the delivery of the foetus begins the third stage. We have now to 
consider the phenomena connected with the expulsion of the placenta. 

During the contractions of labor the placental site diminishes in area, 




Fig. 88. — The amniotic sac projects into the vagina in a long narrow pouch. This happens when the 
head cannot descend, as in pelvic contraction. 



as does the whole uterine interior. Before the rupture of the membranes, 
however, there is no permanent diminution. When the contraction is ove^r, 
however, it resumes its original size, and thus it happens that before the 
rupture of the membranes there is no permanent reduction in the placental 
area and ordinarily no separation of the placenta. During the second 
stage and as a part of the general diminution in the size of the uterus which 
now occurs, the placenta becomes somewhat thickened and slightly folded 
upon itself, especially at the circumference, but there is as yet no 
separation. 

After the delivery of the foetus the uterus is so much reduced in size 
that the separation of the internal surface of the placenta is unavoidable. 



116 PREGNANCY, LABOR AND THE PUERPERIUM 



The placenta has now become a foreign body, and lies unattached in the 
distended lower uterine segment. 

A pause of variable duration now ensues after which the uterus again 
begins to contract, ushering in a second labor in miniature which results 
in the expulsion of the placenta. Owing to the fact that the distended 
lower segment has at this time little contractile power, expulsion may be 
long delayed and interference is often necessary. 

How is the expulsion of the placenta accomplished ? This is a disputed 
matter. Two methods are usually described : the mechanism of Duncan and 




Fig. 89.— Expulsion of the 
placenta according to Baude- 
locque. (Pinard.) o e, external 
os; c c, contraction ring; PI., 
placenta folded together over 
the maternal surface; h, haema- 
toma; vts., bladder; m, mem- 
branes. 




Fig. 90. — Expulsion of the placenta according to Duncan. 
(Charpentier.) 



the mechanism of Schultze. The latter is, perhaps, more properly called 
the mechanism of Baudelocque, since it was described by the latter in 1789. 
Mechanism of Baudelocque or Schultze. — Here the placenta presents 
at the vulva, by its fetal surface, the grayish-blue, glistening surface which 
soon becomes so familiar to those who have watched the process. It 
is the centre of the placenta, <the most vulnerable part, which has separated 
first. Its periphery is still adherent. The blood which has escaped at 
the point of separation can escape no further and a large clot is formed — 
the retroplacental haematoma of Schultze — as it is usually called. There 
is no external bleeding. 



PHYSIOLOGY AND MECHANISM OF LABOR 117 

Mechanism of Duncan. — Here the deep red, maternal surface presents 
at the vulva. The separation has been at the placental border. A moder- 
ate amount of blood escapes. There is of course no retroplacental 
hasmatoma. Nor is there the presenting pouch which is observed in the 
mechanism already described (Figs. 89 and 90). 

\\'hat is the relative frequency of the two mechanisms? This is still 
a matter of controversy. In Germany opinion is divided. In England 
and our own countr)- one hears more of Duncan's method. My own 
observation leads me to believe that the method of Baudelocque-Schultze 
is much more common. This is the conclusion of Fabre, who estimates 
the relative frequency of the two positions as five to one. It is probable 
that the mechanism of Duncan is, as Baudelocque said, an evidence of low 
insertion of the placenta. 

The Mechanism of Labor 

By the term mechanism of labor is meant the mechanical process by 
means of which the foetus, under the influence of the natural expelling 
forces, is enabled to traverse the birth canal, and at length find its way 
into the external world. A'ariations from the typical mechanism are 
the cause of much trouble both to physician and patient, and their prompt 
recognition is absolutely necessary to intelligent prophylaxis or treatment. 
But we cannot recognize the abnormal unless we know the normal. 

It is a strange and regrettable fact that so few students or practitioners 
remember even the normal mechanism. This is due, I think, in part to 
the fact that they are required to learn too much about it. The subject is 
usually made too complex by the discussion of ancient opinions and dis- 
puted theories, and by the inclusion of many statements of doubtful 
accuracy that have been handed down from one text-book to another. 
Moreover it is, in my opinion, a mistake to consider all parts of the subject, 
including the various kinds of abnormal mechanism at the same time. 

Let us consider here the essential facts in connection with the mechan- 
ism of labor in occiput presentations. These make up the great majority 
of all presentations and these alone are to be regarded as normal. It is 
true that the posterior occiput sometimes refuses to rotate anteriorly and 
thus gives rise to trouble. This, however, is exceptional and abnormal 
and will be considered when we take up the subject of posterior positions 
of the occiput. 

Other abnormalities of mechanism will be considered in connection 
with the various malpositions and malpresentations, and in discussing the 
subject of pelvic contraction. 

I would strongly advise everyone who intends to practise obstetrics 
to commit to memory, and frequently to rehearse, the main facts in con- 
nection with the mechanism of normal labor. When he knozcs the normal 
mechanism he will not he slow to recognize the abnormal. 

In the lower animals labor is comparatively easy on account of the 



118 



PREGXAXCY. LABOR AXD THE PUERPERIUM 



small and pointed head, which traverses the pelvic canal, and even the soft 
parts, with but little difficulty. In the human female most of the difficulty 
in delivery is caused by the disproportionately large head of the foetus. 
It is only in rare cases that any other part of the foetus, e.g., the shoulders 
or the abdomen, offers a serious obstacle to delivery. ^lost of the problems 
connected with the mechanism of labor centre about the fetal head and 
its relation to the dift'erent diameters of the maternal pelvis, and to the 
birth canal as a whole, including the soft parts. 




Fig. 91. — Primipara at beginning of labor. Head well flexed. Occiput fixed in pelvis. 



To begin at the beginning, we must ask ourselves the question, What 
is the position of the fetal head at the beginning of labor? This question 
cannot be answered witHoiit qualification. 

In multipara the head is above the pelvic brim, transverse or oblique, 
usually the latter, and only moderately flexed, or perhaps not flexed at all. 
In primiparae it is in the cavity of the pelvis and well flexed. Alany 
physicians do not seem to know this. Many text-books do not seem to 
notice it, or, at least, to emphasize it. It is a fact, however, that should 
never be forgotten, if one would understand the mechanism of labor. 
There are, of course, exceptions to this rule. For example, in the case 



PHYSIOLOGY AND MECHANISM OF LABOR 



119 



of a multipara with very little amniotic fluid, the head may be crowded 
into the pelvic cavity; again, if, in the case of a primipara, the pelvis is 
contracted, or the fetal head very large, the latter may be unable to enter 
the pelvis at all. Nevertheless, the rule is of very general application (Figs. 
91 and 92). 

Recalling these facts, the reader will understand at once that the 
mechanism of labor in multipara is very dillerent from that which obtains 

\ 




Fig. 92. — Multipara. Beginning of labor. Moderate flexion, still movable. Sinciput and occiput 

approximately at same level. 

in primiparse. In the latter, descent and flexion of the head occur long 
before the beginning of labor, while in the former the head usually remains 
above the brim, not only until the beginning of labor, but until the cervix 
has become dilated, the membranes have ruptured, and the first stage of 
labor is complete. 

The movements of the head are denominated, according to ancient 
usage, as follows : Flexion, Descent, Rotation, Extension and External 
Rotation or Restitution. These terms are admirablv clear and definite. 



120 



PREGXANXY, LABOR AXD THE PUERPERIUM 



They explain themselves, and taken together, they tell in large part the 
story of the mechanism of labor. A single word of caution, however. 
These movements occur, not separately, but simultaneously. Thus the 
head does not first become fiexed, then descend, then rotate, etc. Flexion 
and descent go on together, for example, and so may descent and rotation. 
Flexion and Descent. — Let us then return to our multipara, in whom 
labor is about to begin, ^^'e will assume the position to be the usual left 
occiput anterior, the so-called L. O. A. position. Before rupture of the 
membranes, there has been little or no advance of the head, which remains 
above the brim in a position midway between flexion and extension. The 
long occipitofrontal diameter presents. The cervix has become dilated 
and the membranes have been ruptured. The expelling forces now have 
free play. L'nder their influence descent begins, but it is the occiput 
that descends first. In other words, flexion occurs. What is the cause 
of flexion ? The propelling force is transmitted through the spinal column 




Fig. 93. — Shows why the head does not engage in the transverse diameter of the superior strait. 

of the foetus to the fetal head. But the spinal column does not articulate 
with the middle of the head. Its point of articulation is much nearer 
the occiput. Therefore, as soon as the anterior pole of the head comes 
in contact with the brim of the pelvis the head becomes flexed, the occiput 
descending in advance. \\'hen the greatest circumference of the head 
has entered the brim engagement is said to have occurred. 

We have now learned the cause of flexion. AMiat is its object? 
Plainly, the substitution of the short suboccipito bregmatic diameter, for 
the long occipitofrontal diameter which presented while the head was 
still above the brim. This substitution, of course, enables the head more 
easily to enter the pelvic brim, and more readily to traverse its subsequent 
course. As the head descends into the cavity of the pelvis it remains 
flexed, thus maintaining its smaller diameter and making descent more 
easy. Descent of the occiput as indicated by a low position of the small 
fontanelle is, except in cases of flat pelvis, of favorable import. 

But let us return a moment to the head, as it is about to enter the 



PHYSIOLOGY AXD .MECHANISM OF LABOR 121 

brim of the pelvis. At first thought one would suppose that the head 
would enter transversely, but as a matter of fact it usually enters in 
one of the oblique diameters ; in this case, of course, the left oblique. 
AMiat is the reason for this? The projecting promontory of the sacrum 
prevents it from utilizing the transverse diameter. This is clearly shown 
in the accompanying illustration (Fig. 93). 

Still another point with reference to the entrance of the head into the 
brim. It was taught by Naegele that the head enters the brim obliquely, 
the anterior parietal bone presenting, and the sagittal suture near the 
promontory, the so-called biparietal obliquity of Naegele. This is, it is 




Fig. 94. — Synclitic or parallel entrance of head into pelvic brim 



true, frequently the case in contracted pelvis, or in pendulous abdomen, 
when the breech falls forward and the head points backward, but abundant 
observation has proven that in normal cases the head enters the brim of 
the pelvis directly, that is with the sagittal suture midway between the 
symphysis pubis and the promontory of the sacrum (Figs. 94, 95 and 96). 
Rotation. — We have now seen how the head becomes flexed and 
enters the cavity of the pelvis. Lender the influence of the same forces, 
descent continues and at the same time a new movement occiu'S : the 
movement of rotation, by which, as the head continues to descend, the 
occipital pole rotates to the front, until the head comes, at the outlet, to 
occupy the anteroposterior diameter, the occiput presenting beneath the 
pubic arch. 



122 



PREGNANCY, LABOR AND THE PUERPERIUAI 



What is the cause of this rotation? A most interesting and important 
question. 

Several theories have been advanced. In the first place, the pelvis is 
said to have a spiral or corkscrew form, its transverse diameter being 
greatest at the brim, while its anteroposterior diameter is greatest at the 
outlet. This is perhaps true if we include the soft structures of the 
pelvic floor, but if we regard the bony pelvis alone, it is little more than 
a time-honored fiction. If one looks at an articulated pelvis, it requires 
a vivid imagination to discover this corkscrew form, or to make out that 




Fig. 95. — Posterior asynclitism. 

the anteroposterior diameter of the outlet is much greater than the 
transverse. 

Another alleged factor is the lessened resistance anteriorly at the sub- 
pubic arch. It is claimed that here the occiput rotates in the direction of 
least resistance. 

Still another theory is that the thrust of the lateral pelvic walls, or 
pelvic planes, as they are often inaccurately called, determines the rotation 
of the occiput. 

Sellheim has recently sought to explain the rotation of the occiput, as a 
species of accommodation of the foetus to the pelvic canal. The back 
of the neck, the point at which the greatest bending of the fetal body is 



PHYSIOLOGY AND MECHANISM OF LABOR 



123 



permitted, must come into contact with the subpubic arch, before the 
movement of extension of the head, which is absolutely essential to 
progress, can occur. DeLee has very aptly compared this to the movement 
which occurs when the foot, pointing '* sideways," is pushed into a boot, 
the foot rotating as it advances until the curve of the ankle corresponds 
with the curve of the boot. 

All these theories are, in my opinion, discredited by the fact that in 
many cases rotation does not occur until the head has reached the floor 
of the pelvis. It is the observation of every watchful obstetrician that, in 




Fig. 96. — Anterior asynclitism. 



multiparse, rotation and expulsion are almost simultaneous. This leads 
me to believe that whatever effect the above mentioned factors may have 
in determining rotation the principle role is played by the soft parts. 

The accompanying illustration (Fig. 97) shows the floor of the pelvis 
as viewed from above, and it is easy to see how the descending head 
becomes adapted to the anteroposterior gutter formed by the soft parts. 
Indeed it is difficult to see how it could do otherwise. It is also plain 
that rotation would occur earlier in the case of a primipara with tense, 
resistant, and intact pelvic floor, than in that of a multipara with lax and 
perhaps lacerated tissues ; and this T have often found to be the case. 



124 PREGNANCY, LABOR AND THE PUERPERIUM 



We have tried to show why the head rotates, but there remains an 
important question to be answered. Wliy does it rotate anteriorly ? What 
is the provision of nature that saves the patient from a posterior position 
of the occiput with its attendant disadvantages? In my opinion the best 
answer to this question has been furnished by Ohlshausen, who beHeves 
that the head rotates anteriorly because its posterior rotation would be 
prevented by the fetal trunk which maintains the position which it occupied 
before labor, i.e., with the back anterior. The reason for this anterior 
position of the back we have already considered. 

When does rotation occur? At what point in the pelvis? 

There is no fixed point. In primiparse it usually begins in the mid- 
pelvis, though it may begin higher. In multiparas, if the head is not over 




Fig. 97. — Pelvic floor, viewed from above, a, ischio-cqccygeus muscle; h, iliac portion of the levator 
ani; c, pubic portion of the levator ani; d, arcus tendinus (Bumm). 

large, it may, and often does, remain transverse until the last moment, 
rotating only when it is well down upon the pelvic floor. 

The cause of rotation then is to be found chiefly in the soft structures 
of the pelvic floor. Its subject, of course, is to bring the occiput beneath 
the pubic arch so that the shorter suboccipito bregmatic diameter may be 
opposed to the scanty space afiforded by the vulval orifice. 

What is the degree of rotation? In anterior cases about one-eighth 
of a circle, as shown in Figs. 98 and 99. When the occiput is posterior the 
distance is about three-eighths of a circle; see Figs. 100 and loi. 

All this time descent continues. When, however, the occiput becomes 
fixed under the pubic arch, the expelling forces continuing to act in the 
same line as before, i.e., in the line of the pelvic brim, the back of the 
neck becomes firmly fixed against the inner aspect of the pubis, preventing 
further advance of the occiput. The propelling force is now expended 



PHYSIOLOGY AND MECHANISAI OF LABOR 



125 



upon the frontal end of the head, and this can only result in extension by 
means of which the occiput, vertex, brow and face are successively made 
to emerge over the perineum in a manner too familiar to need description. 

The movement of extension is materially aided by the upward pull 
of the distended and elastic perineum. 

Following the delivery of the head the shoulders rotate into the 
anteroposterior diameter of the outlet, and the head, turning with them, 
assumes a lateral position, the occiput pointing in the direction of the 
side toward which it was originally directed, i.e., in the L. O. A. position 



toward the left side, and vice versa. 

Fig. 98. 




It is the shoulders that rotate, and 



Fig. 99. 




Fig. 98. — Position, L. O. A. Degree of rotation in anterior cases, one-eighth of a circle. 
Fig. 99. — Position, R. O. A. Degree of rotation, one-eighth of a circle. 

the head follows. This final movement of the head is known as external 
rotation or restitution. 

Delivery of the Shoulders. — After the delivery and rotation of the 
head there is a short pause, during which nature seems to gather her 
energies for the little work that is left. Just how long this interval would 
last few of us know, for few of us have the " repose " to wait. AMien it 
is over, or when uterine action is started by pressure upon the fundus, 
the anterior shoulder descends and becomes fixed beneath the symphysis, 
very much as the occiput does before the delivery of the head. The pro- 
pelling force continuing, the posterior shoulder sweeps over the perineum, 
as do the forehead and face after the delivery of the occiput. 

Superrotation of the Head. — An occasional anomaly is the so-called 
superrotation of the head, which is really nothing more than superrotation 



126 PREGNANCY, LABOR AND THE PUERPERIUM 

of the shoulders. For example, a head presenting in the L. O. A. position 
rotates under the pubic arch, but instead of stopping there, continues its 
rotation until it comes to occupy the R. O. A. position. If this occurs 
before delivery, as it sometimes does, it is usually overlooked ; though 
if a careful external and internal examination were made, it would show 
the back directed toward one side and the occiput toward the other. 
This phenomenon is of no great clinical importance, but may lead the 
attendant, or, what is more embarrassing, some one else, to the mistaken 
assumption that his original diagnosis of the position was incorrect. 

I cannot dismiss this subject without reference to a factor which has 
much to do with the mechanism of labor, but which is not usually men- 
tioned in connection with the subject. 



Fig. 100. 



Fig. ioi. 





Fig. 100. — Position, R. O. P. Degree of rotation in posterior cases about three-eighths of a circle. 
Fig. ioi. — Position, L. O. P. Degree of rotation about three-eighths of a circle. 



Fortunately the fetal head is not a hard, incompressible body like a 
glass ball. If it were we would meet with disaster in almost every case. 
The cranial bones are thin and flexible, and the sutures permit their 
free overlapping. Thus it happens that during labor, and especially when 
labor is long delayed, or when there is much disproportion between the 
head and the birth canal, as in pelvic contraction, or when the head is of 
unusual size or when, as in various malpresentations, it presents by one of 
the larger diameters, it becomes moulded to the canal through which it 
must pass. As we shall see later, this moulding is sometimes very marked 
and often enables nature to overcome obstacles that at first sight seemed 
impassable. 



PHYSIOLOGY AXD MECHANISM OF LABOR 127 

The head of the premature foetus moulds almost like wax. This 
malleability becomes less as pregnancy advances, though it is sufficient at 
term to overcome considerable disproportion provided the uterine con- 
tractions are satisfactory. The heads of negro children are somewhat 
smaller and more malleable than those of the white race. Hence, although 
moderate pelvic contraction is common among negroes, their labors are 
usually easy. 

The head, however, increases rapidly, not only in size but also in hard- 
ness, during the latter weeks of pregnancy. It is especially in cases in 
which the patient has gone a week or two over her allotted time that the 
head is very incompressible, and this fact helps to account for the great 
difficulty often encountered in these cases. 

Let me entreat the reader not to neglect the study of the physiology and 
mechanism of labor. To attempt to memorize all that is sometimes written 
about it is folly. But every one should master the essentials. He will 
then understand the phenomena of labor as he never could understand 
them otherwise. He will find the study highly interesting in itself, and 
what is more important he will not fail to make practical application of his 
knowledge in the interest of those entrusted to his care. 



CHAPTER VII 
THE DIAGNOSIS AND CLINICAL PHENOMENA OF LABOR 

Labor does not come suddenly, like a flash from a clear sky. There 
are certain well-defined warnings, not difficult to recognize, with w^hich the 
practitioner, and, indeed, the patient herself, if she has been pregnant 
before, soon becomes familiar. 

Premonitory Symptoms. — About three weeks before labor begins, the 
fundus uteri, which by this time has reached, or nearly reached, the xiphoid 
cartilage, sinks downward and somewhat forward, until it comes to occupy 
the position w^hich it occupied four weeks earlier. This phenomenon is 
more marked in primiparse. It is at about this time that in these cases the 
head becomes deeply engaged in the pelvic cavity. In multiparse the for- 
ward movement of the fundus predominates, causing a somewhat pen- 
dulous condition of the abdomen. As we have already seen, the head in 
multiparse usually remains above the brim until the beginning of the second 
stage of labor. 

This sinking of the fundus, or '' lightening," as it is sometimes termed 
by the laity, relieves certain symptoms caused by the upward pressure of 
the uterus, e.g., dyspnoea and indigestion. In primipar?e, however, this is 
more than counterbalanced by the " bearing down " sensations, the diffi- 
culty in walking and the frequent urination that accompany the descent of 
the head into the pelvis. Another premonitory symptom, common at this 
time, is a marked increase of the vaginal secretion, which is sometimes a 
source of considerable annoyance to the patient. The painless contrac- 
tions of pregnancy become more frequent and pronounced especially at 
night and in the early hours of the morning. Sometimes they closely 
simulate genuine labor pains and one has to wait a few hours before making 
a positive diagnosis. This brings us to an important question. 

The Diagnosis of Begixxing Labor 

^^llen does labor begin? ^Miat are the evidences that it really has 
begun ? 

Little attention is usually given to the diagnosis of beginning labor. 
This, I believe to be a mistake. Xeither practitioner nor student knows by 
intuition what constitutes real labor. Stereotyped rules and didactic 
teacliing often leave him in doubt. The symptoms of labor as usually 
given are pain and dilatation of the cervix, and yet both these symptoms 
may be present long before labor begins. 

I recall a case that I saw with the students in the out-door department 
of a maternity hospital. It was reported as a case of delayed labor, and 
the students could not be blamed for following their text-books. Indeed, 
128 



CLINICAL PHENOMENA OF LABOR 



129 



according- to the definition so often given, the patient was in labor, for she 
had both pain and dilatation of the cervix. Vaginal examination, however, 
showed that true labor had not begun and the pains were recognized as 
those indefinite and irregular pains so common in multiparse. The stu- 
dents were relieved from further anxiety about the case, and the patient 
v/as not delivered until some weeks later. 

The dilatation in this case was the usual dilatation of a multiparous 
cervix in the latter weeks of pregnancy. In these cases it is almost always 
possible to pass one or even two fingers, not only through the external, but 
through the internal os. long before the beginning of labor. At this time 
the cervix in a multipara has the shape of an inverted funnel. The external 
Fig. 102. Fig. ^03, 





Fig. 102. 



-Cervix of multipara before beginning of labor. Dilatation without effacement. 
Fig. 103. — Cervix of primipara at beginning of labor. 



OS is larger than the internal. As long as this shape is maintained, the 
patient is not in labor, no matter how great the dilatation, or how severe the 
pain (Fig. 102). At the beginning of labor the internal os begins to soften 
and to dilate. The funnel is no longer inverted (Figs. 103, 104 and 105). 

Fig. 104. 

Fig. 105. 





Fig. 104. — Cervix of primipara. Beginning effacement. 
Fig. 105. — Cervix of primipara. EfiEacement complete. Beginning dilatation. 

In primiparse the external os is firm, and the canal cylindrical or spindle- 
shaped, rather than funnel-shaped. There is usually much less dilatation, 
the external os, as a rule, barely admitting the tip of the finger. Even here, 
however, there are numerous exceptions, and not infrequently the examiner 
will be surprised to find that one or even two fingers may be passed without 
difficulty through both orifices. 

Dilatation, then, is not in itself evidence of beginning labor. It is the 
kind of dilatation that counts. 



130 PREGNANCY, LABOR AND THE PUERPERIUAI 

If one is called at an early stage of labor, i.e., before obliteration of the 
cervical canal, labor may be suspected from the fact that the internal os is 
beginning to soften, and that it is larger than the external. Now and then 
in the course of an antepartum examination I have thus diagnosed begin- 
ning labor, although the patient had complained of no special pain. As a 
rule, however, by the time the physician is called the internal os has dis- 
appeared, the canal of the cervix has been obliterated, and all that one feels 
is the sharp edge of the external os. 

There is usually little difficulty in determining the commencement of 
labor in primiparse. As a rule, the cervix remains closed until labor begins, 
and by the time that dilatation is noticeable the other signs of labor are 
unmistakable. In those cases in which the canal is dilated before labor the 
diagnosis may be made in the manner already described. The student 
should have impressed upon his mind the fact so often ignored or un- 
noticed that the evidences of beginning labor are not the same in primipar?e 
as in multiparse. With reference to prognosis he should remember that 
dilatation of the internal os is the diagnostic index of the progress of the 
first stage of labor in multiparge as is dilatation of the external os in 
primiparse. 

It is no wonder that the modem medical student is sometimes bewil- 
dered. He will find in standard text-books the astonishing statement that 
the cervical canal remains closed until the very beginning of labor, and he 
is also told that dilatation of the cervix and obliteration of its canal are 
the chief objective signs of labor; but if he is an observant man and has 
opportunities for examination, he will find, to his surprise, that occa- 
sionally, in primiparse, and, as a rule, in multiparse, the cervical canal is 
dilated for its entire length to the point of admitting one or two fingers 
long before labor begins, and that, especially in multiparae, obliteration of 
the canal usually means not only that labor has begun, but also that a large 
and, clinically, an important part of the first stage has been completed. 
Unless, however, he is taught these things at the outset of his practical 
work, he will learn them only as the result of many mistakes, much personal 
inconvenience and chagrin, and perhaps at the expense of the welfare of 
his patients. 

The signs of labor then that are available for diagnosis, are the disap- 
pearance of the internal os, and the obliteration of the cervical canal. It 
is true that this condition, or something very much like it, is sometimes 
found in conditions of great distention, e.g., hydramnion, or twin preg- 
nancy, long before labor begins, but in these cases pain, if present, is in- 
definite and irregular. When the cervical canal is obliterated, and the 
patient has true rhythmical pains she is undoubtedly in labor. 

The Contractions of Labor. — The advent of true labor, then, is 
marked by regularly recurring " pains.'' These are about twenty minutes 
apart, sometimes thirty minutes. At first they excite little or no attention, 
but as the hours pass they gradually increase in frequency and severity 



CLINICAL PHENOMENA OF LABOR 131 

until it is evident, even to those of little or no experience, that something 
unusual is in progress. The popular term " pain," as a substitute for con^ 
traction, has become so imbedded in the literature of the subject that it is 
difficult to separate the two words. 

After all, the history of labor is the history of the contractions by 
which the uterus finally expels its contents. Let us consider these con- 
tractions somewhat in detail. 

How do they begin ? Sometimes suddenly ; that is, the pain begins 
suddenly. As we have already seen contractions have been going on for 
months, but up to this time they have not been painful. 

In other cases true labor has been preceded by days of discomfort, and 
the transition from pregnancy is so gradual that it is impossible to say when 
pregnancy stops and labor begins. My own belief, which I have expressed 
elsewhere, is that pregnancy and labor are one process, that there is no 
sharp line of demarcation between them, that contraction, not pain, is the 
essential element in labor, and that pain is a clinical not a physiological 
distinction. 

However, we must have some clinical evidence of the beginning of 
labor. Ordinarily that evidence consists in the fact that uterine contrac- 
tions that have hitherto been painless, become painful, and this usually 
coincides with beginning dilatation of the internal os. 

In reading various descriptions of the process of labor one cannot but 
be impressed by the fact that most men have been content with superficial 
observation, and have described the pains or contractions, not as they 
have found them by careful study, but as, reasoning from analogy, they 
have thought that they ought to be. Most writers describe the contractions 
as increasing steadily in frequency, duration, force, and intensity from 
the beginning to the end of labor. Such descriptions are incorrect, and 
more accurate knowledge is essential if one would know the natural history 
of labor, and thus be in a position to recognize departures from the normal. 

Frequency. — The first contractions are about twenty minutes apart. 
During the first stage, i.e., up to the period of full dilatation of the cervix, 
they increase progressively in frequency, until the interval has been reduced 
from about twenty minutes to about three minutes. During the stage of 
expulsion they become somewhat less frequent, the interval being about 
five minutes. During the dilatation of the vulva, however, they become a 
little more rapid. 

Duration. — The contractions of beginning labor are not more than five 
or ten seconds long, but their duration increases progressively up to the 
end of the first stage, when they may be a full minute in length. Their 
duration is not progressive however during the second stage. During this 
stage they are about twenty or thirty seconds in length, each complete 
contraction representing a group of two or three shorter ones, each about 
ten seconds in length (Fabre). Of course the pains seem much longer 
than they really are. 



132 PREGNANCY, LABOR AND THE PUERPERIUM 

LocATiox. — At first the pain is felt in the back or lumbar region and 
radiates, or as the patients often say " comes around," to the groins and 
lower abdomen. Later, however, the pain becomes localized in the supra- 
pubic region, where it usually remains until the second stage is well under 
way. As the head approaches the pelvic floor the patient complains of a 
sensation of great pressure in the neighborhood of the perineum and 
rectum, while during the stage of expulsion the pain is referred to the 
orifice of the vagina. 

Character axd Ixtexsity of the Paixs. — The first pains are slight 
and are often regarded by the patient with interest and curiosity. At first 




Fig. 



io6. — Method of internal hysterography. M, manometer; R, reservoir; slow tracing; rapid tracing; 
T, transmitter; B, de Ribes bag. 



they resemble intestinal cramps for which indeed they are often mistaken. 
They increase progressively in severity, however, until the cervix is nearly 
or quite dilated. At this time they are very often severe, exceeding in 
intensity those of the second stage.' The French writers have graphically 
described this part of labor as the periode de dcsespoir, and so it often 
seems. 

As the head descends into the vagina, the great ner\'e ganglia about the 
cervix are to some extent relieved from pressure, and, as we shall see 
presently, the pains, though still severe, are better borne by the patient. 
As the head emerges from the vulva the pain again becomes acute, especially 
in primiparae. Fortunately this stage is of short duration and we have 
means for its mitigation. 



CLINICAL PHENO^IENA OF LABOR 



133 



Force Exerted by the Uterine Contractions. — Various methods 
have been used in the attempt to estimate the pressure brought to bear 
upon the uterine contents during a contraction. One of these methods 
is to attach a manometer to a de Ribes bag introduced within the cervix. 
Another method is to stretch a segment of amniotic sac over the orifice of 
a tube ten centimetres in diameter, this being the average diameter of the 
cervix at the time of rupture of the membranes, and determine the force 
required to elTect rupture. Still another method is to hold back the head, 
and estimate the force thus expended. As a result of these different 
methods it has been estimated that in normal labor the force varies between 




Fig. 107. — Combined method, (internal and external). M, manometer; R, reservoir; E, external 
hysterography; I, internal hysterography; T, transmitter; B, de Ribes bag. 



five and fifteen kilogrammes, and that in difficult cases it may reach twenty- 
five kilogrammes (Figs. 106 and 107). 

Why Are the Contractions Accompanied by Pain? — What is the 
cause of the pain that is experienced during a uterine contraction? This 
has been the subject of much discussion. 

The most severe pain is experienced at the moment of complete dilata- 
tion of the cervix, and again when the head is passing the orifice of the 
vulva. This is sufficiently explained by the abundant nervous supply of 
these parts. 

The compression of the nerves of the uterine wall during the contrac- 
tions is often invoked as another cause. 

Compression of branches of the lumbar and sacral plexus that pass over 
the brim of the pelvis accounts for the painful cramps in the thighs that 
form an unpleasant feature of the second stage. 



134 PREGNANCY, LABOR AND THE PUERPERIUAI 

But without going into detail, one may say that the question is hardly 
worthy of extended answer. No one considers it necessary to explain why 
the passage of a gall-stone through the common duct causes severe pain. 
Still less need we wonder that the passage of a body so large and hard as 
the fetal head, through so relatively small a channel as the birth canal, is 
productive of much suffering. 

Attitude of the Patient During the Contractions. — During the 
first stage the patient prefers to walk about, but during a pain she remains 
standing, with the body bent forward and the hands clenched or grasping 
some stationar}^ object, only to resume her walk when the pain is over. 
There is no " bearing down " at this time nor should there be. The con- 
tractions are those of the uterine muscle and are altogether beyond the 
control of the will. 

During the stage of expulsion there is a tendency for the patient to 
assume the kneeling or squatting position, or if in bed to flex the thighs 
upon the body, grasp the hands of the nurse and press her feet against some 
stationary object, thus aiding the process of expulsion by her own efforts. 

Very timid or nervous women will sometimes refuse to do any of 
these things, and from fear of pain will resist all impulses and disregard all 
directions to " bear down." This may often be remedied by a little 
primary anaesthesia with ether. 

Objective Signs of Uterine Contractions. — Strangely enough the 
beginning of a contraction may be recognized by the onlooker before it is 
felt by the patient. It is appreciable both to the eye and the hand of the 
practised observer. As the contraction begins, the uterus, owing to the 
increase in its anteroposterior diameter, and to the downward and forward 
pull of the round ligaments, seems to approach the abdominal surface, and 
its pear-shaped outline becomes plainly visible through the stretched and 
thinned abdominal wall. At the same time the hand placed lightly upon 
the surface distinctly feels the hardening of the uterus (Fig. io8). 

All this, however, is true of the painless contractions of pregnancy, 
except that the uterus does not become as hard as it does in active labor. 
It does harden to some extent, however. 

Owing to the thickening and hardening of the uterine wall during a 
contraction the foetus cannot be outlined and external palpation gives no 
results. It can be practised with facility, however, during the intervals. 

During a contraction the fetal heart beats more slowly, and at the height 
of a contraction it is heard with difficulty. With the subsidence of the 
contraction it resumes its normal rate. 

Effect of the Contractions Upon the Patient. — The first pains 
are so^ slight that they cause little disturbance of any kind. As the hours 
pass, however, and they increase in force and frequency, the pathetic 
moment arrives when the patient begins to form some conception of the 
ordeal before her. 

After a few hours the pains have reached such a degree of severity that 



CLIXICAL PHEXOMEXA OF LABOR 



135 



their effect upon the organism can be noted. During a contraction the 
pulse becomes more rapid, and the arterial tension is increased. 

There is said to be a slight rise of temperature, but it is so slight as to 
be practically insignificant. There is, howeixr, a slight progressive rise of 
temperature during labor, especially if labor is prolonged or difficult. Of 
this we shall have occasion to speak later, in considering the clinical 
phenomena of the puerperium. The increase in the arterial tension 
causes an increased secretion of urine, and the patient often perspires 
freely as the result of the eff'ect upon the nervous system of pain and 
anxiety, to which is added, in the second stage, the factor of great muscular 
exertion. The abdominal pressure makes respiration somewhat slower 




-'Jpyri^ht, lyij, D, A; pleton >>>; Co. 

Fig. io8. — Composite picture showing abdominal outline before and during 

Williams.) 



contraction. (After 



during a contraction, and as a consequence, somewhat more rapid 'during 
the intervals. 

There is a marked leucocytosis during labor, which continues for sev- 
eral days. Its origin is uncertain but the importance of its recognition is 
obvious. For example, in cases of suspected infection it is plain that an 
increased leucocytosis does not have the same significance as at other 
times. 

After the rupture of the membranes the patient is granted a brief 
respite from her sufferings. This lull is deceptive to the inexperienced. 
The amniotic fluid dribbles away but there is little or no pain. This rest is 
of short duration. Five minutes, perhaps. X^ature is gathering her forces 
for the final effort. It is the beginning of the end ; Die Ritlie vor dcm 
Sturme, as Bumm eloquently phrases it. The pains recommence, but they 



136 PREGXA^XY, LABOR AXD THE PUERPERIUM 

have assumed a different character. As already stated, they are less fre- 
quent and for a time at least less acute. But as the head approaches the 
floor of the pelvis the tremendous downward pressure alarms the patient 
who feels her powerlessness to resist it. 

On the whole, however, these pains are better borne than those that 
have gone before. She feels conscious of some progress, feels that she 
can help herself. ^Moreover the cerebral congestion attendant upon the 
bearing down eft'orts induces a sort of physiological anaesthesia. During 
the final act of expulsion the pain again becomes insufferably acute, the 
patient perhaps crying out that she is being torn apart, but now a few 
drops of ether may well perform their merciful office and draw a curtain 
over this climax of suffering. 

We have considered the mechanism of the expulsive stage in a previous 
chapter and there is little need of dwelling here on the clinical phenomena 
of this period. 

As the head reaches the pelvic floor the straining efforts are redoubled 
and the facial congestion is more marked. Pressure upon the rectum 
causes the patient to think that she must go to stool, which, of course, can- 
not be allowed at this time. Faeces are often indeed usually squeezed from 
the rectum by the pressure of the head. This is a very significant and 
positive sign of approaching delivery. 

The next thing noted upon inspection is a slight bulging of the skin 
surface of the perineum, followed by beginning separation of the labia. 
This separation becomes greater with successive pains and soon the 
occiput appears at the height of a pain only to recede as the pain subsides. 
But now a segment of increasing size appears with each pain. 

Meanwhile the perineum becomes stretched and thinned over the ad- 
vancing head until the distended vaginal orifice looks directly upward. 
The anus, too, is dilated and the rectal mucous membrane visible 
posteriorly. The occiput becomes fixed under the symphysis, and as 
extension occurs brow, nose, mouth and chin sweep successively over 
the perineum. 

This description need not be prolonged. Those who have witnessed 
the process need no description and those who have not must witness it in 
order to appreciate it. Opportunities are frequent and there is no other 
way. 

Atypical Labor. — Of course labor does not always proceed in the 
typical fashion outlined above. \'ariations from the usual order are com- 
mon enough, and the observant practitioner will soon learn to recognize 
them. He should accustom himself early in his career to watch the 
progress of labor, and later when he has less time for such watching he 
will realize that the time was well spent. 

In some cases the painless contractions of pregnancy gradually lose 
their innocent character and by degrees become quite painful, but the 
process is so slow that it is hard to tell when pregnancy stops and labor 



CLINICAL PHENOMENA OF LABOR 137 

begins. Again labor may make several false starts, as it were, before 
continuous labor is established. Now and then the pains are in pairs, first 
a slight one, then a severe one. In certain cases, fortunately rare, the onset 
of labor is sudden and its progress rapid and stormy from the start. Early 
in labor the pains become frequent and severe, occurring at intervals of 
three or four minutes during the entire first stage, the patient thus getting 
but little of the merciful relief usually afforded by nature. Far more 
commonly, however, the first stage is prolonged, the contractions while 
painful having but little effect in causing dilatation of the cervix. These 
cases are most apt to occur in women of the neurotic type, or there may 
be no apparent reason for the delay. Alost common of all is simple delay 
in the second stage. The patient is either exhausted and cannot, or is 
frightened, and will not use her voluntary muscles. All these variations, 
if extreme, become pathological and will be dealt with when we come to the 
pathology of labor. 

Some labors are almost painless. Now and then in multiparse the water 
breaks while the patient is sleeping, and labor is completed with one or 
two pains. But these cases are not common. No race or class seems to 
be immune to the suft'erings of labor, which are apparently the penalty of 
belonging to the human race. The comparatively larger size of the head 
in man undoubtedly affords the chief explanation. Those who hold the 
evolutionary hypothesis believe that the gradual assumption of the erect 
position involved certain pelvic modifications that have added to the 
difficulty. However this may be, the facts remain. 

It is commonly supposed that working women, and strong and vigorous 
representatives of the wealthier classes, have easy labors. If any such rule 
exists it is certainly subject to many modifications. Weak, delicate, and 
anaemic women often have easy labors, while athletes are proverbially 
difficult cases. 

Not infrequently one hears those of little knowledge and ready assump- 
tion assert that women of primitive races, e.g., Indian women, have easy 
labors and rapid recoveries, the conclusion, expressed or implied, being 
that normal labor needs little supervision. These statements are not justi- 
fied by the facts. I have been assured by physicians of experience, post- 
graduate students at the New York Polyclinic, that death in labor is not 
infrequent among Indian women, and that bad after results, e.g., uterine 
prolapse, are common. 

I do not recall seeing the statement in print, but it is my experience, 
that, other things being equal, tall and slender women have easy labors, 
and that labor is more difficult in stout women. But of course such rules 
are subject to many exceptions. In a multipara with capacious vagina and 
vulva, a few pains often suffice to end the second stage, even when the first 
has been long and tedious. 



CHAPTER VIII 
THE MANAGEMENT OF LABOR 

General Coxsideratioxs 

Labor, it is true, is a natural process, and the ideal case, under ideal 
circumstances, would need no medical treatment at all. This, however, is 
a theoretical proposition. Such conditions do not obtain in practice. 
There is no case in which intelligent medical care cannot do something to 
alleviate suffering, to forestall complications, to maintain asepsis, to 
prevent laceration, or to conserve the life of the foetus. 

But it should be remembered that medical supervision does not always 
mean interference with the processes of nature. The physician should 
endeavor to draw a sharp line between normal and abnormal cases. In 
the latter, prompt and intelligent interference may be imperatively de- 
manded ; in the former, his attitude should be one of prophylaxis and 
watchful attention. 

But if one is- to recognize abnormal labor, he must first know thoroughly 
the phenomena of normal labor. This may mean hard work, loss of sleep, 
and absence from other and better paying work ; but he who is not willing 
to pay this price should adopt a calling less arduous than that of the 
obstetrician. Xow and then one meets a student who is not satisfied with 
anything less than a C^esarean section, but who does not know how to 
locate the fetal heart or the fetal head. Again, one sees an article by some 
justly celebrated surgeon or gynaecologist describing an abdominal or 
vaginal Caesarean section, and reading between the lines, discovers that the 
operator might have accomplished the same or a more favorable result by 
less radical measures, had he had a good obstetrical training. 

The physician who interferes least with nature's processes in normal 
labor is the best physician, but this attitude of expectancy assumes that he 
is prepared to anticipate, and competent to recognize, any departure from 
the normal, and that he is sufficiently intelligent to recognize that nature's 
efforts are not always sufficient, but must sometimes be supplemented by 
the resources of art. 

Preparatiox" 

So far as the physician is concerned, the most important part of the 
preparation has been made in the antepartum examination already de- 
scribed. If that examination has shown that the position, presentation, 
and pelvic measurements are normal and that no complications are present, 
and if a thoroughly good nurse is in attendance, he feels that the interests 
of his patient have not been neglected. He should instruct the nurse to 
notify him at once when labor begins, unless it begins in the middle of the 
138 



THE ^lANAGEAIENT OF LABOR 



139 



night or in the early hours of the morning. In such cases a good nurse may 
often save the physician a few hours of sleep without in any way endan- 
gering the patient. If, however, the physician has not seen the patient 
before, or if there is any suspicion of abnormality, he should, of course, 
respond at once. 

The Physician's Outfit. — Elaborate and costly outfits are recommended 




Fig. 109.- 



-Delivery bag with physician's outfit. (Bellevue Hospital School for Midwives, New York 

City.) 



in various quarters, each writer seeming to strive to outdo the others in 
complexity and impracticability. The result has been that most practi- 
tioners pay no attention whatever to text-book directions, each one devising 
some plan for himself. I will mention here only those things which experi- 
ence has taught me are absolutely necessary, leaving it to the individual 
practitioner to modify or add to the list as experience may dictate. 



140 PREGNANCY, LABOR AND THE PUERPERIUM 

First of all, since they are needed in every case, are materials for disin- 
fection, including green soap, tincture of iodine, bichloride tablets or lysol. 
Personally, I long ago discarded bichloride tablets for reasons which will 
presently be explained. To the above should be added a sterilized nail 
cutter and cleaner, sterilized nail brushes, and, above all, sterilized rubber 
gloves. A sterile gown should always be at hand. In its absence, or in 
emergencies, a substitute may be improvised. 

Drugs should include ether (never to be forgotten), chloroform, some 
preparation of ergot which can be used hypodermatically, and with this, of 
course, a hypodermic syringe which has recently been tested, /\mpoules 
of pituitrin are a desirable addition to the outfit, as are also the various 
hypodermic tablets for emergency use, not forgetting morphine, sometimes 
very useful in delayed labor and in cases of hemorrhage or shock. A small 
quantity of silver nitrate solution (one per cent.) should always be at hand 
as a prophylactic against gonorrhoeal ophthalmia, and its omission is to be 
regarded as a serious error. A solution of chloral hydrate (gr. xv to the 
drachm) is a great boon in cases of delayed and painful labor, especially 
in neurotic subjects. Tablets for making salt solution are useful in 
emergencies. 

Instruments and Appliances. — The forceps, of course, should not be 
omitted. He who would be completely equipped, should have two pairs, — 
a Tarnier instrument for the difficult cases, and one of lighter construction 
and more moderate pelvic curve for the easier cases (see page 578). A 
tenaculum forceps or, better, two should always be at hand. Such a 
forceps is indispensable in hemorrhage from the cervix and very useful in 
perineorrhaphy. A tongue forceps and a laryngeal tube for use in 
asphyxia neonatorum, scissors for cutting the cord and for other purposes, 
needles, some large and strong with the curve of a silver dollar, for making 
the circuit of deep tears, others light and of smaller curve for fine or super- 
ficial suturing, and a good needle-holder must not be omitted. The physi- 
cian should carry suture material in abundance ; silkworm gut for ordinary 
tears, and catgut for buried sutures, necessary in tears of the third 
degree. A long dressing forceps, a thumb forceps, and a few artery- 
clamps should be added. A long soft rubber catheter is an absolute 
necessity. 

Recalling the ever-present possibility of hemorrhage, it is never wise 
to be without a fountain syringe, though this should usually be provided 
by the patient. An intra-uterine douche-tube of glass should be a part of 
every outfit, since a hot douche may be necessary. Material for packing 
the uterus should never he left at home. This should be in the form of a 
few sterile gauze bandages four inches in width. A leg-holder of the kind 
elsewhere illustrated is simple, cheap, and very useful. Under no circum- 
stances should the physician leave his stethoscope at home, especially if 
he is unaccustomed to listening to the fetal heart with his naked ear. 

Kelly's pad and similar devices are cumbrous, difficult to disinfect, and 



THE MANAGEIMENT OF LABOR 141 

quite unnecessary. I have found them a positive nuisance in obstetric 
operations. The pad is sure to become displaced during forceps opera- 
tions or version. A more useful appliance may be improvised from a piece 
of white oilcloth or even from newspapers, and covered with a sterile sheet. 

Trays and pans for sterilizing instruments and appliances occupy a 
great deal of room and are usually too small. Indeed a tray that will con- 
tain water enough to cover the Tarnier forceps will fill a large bag. Some- 
thing must be supplied or improvised, however. A wash boiler makes an 
excellent substitute. A fish kettle with rack such as can be found in any 
hardware store is very convenient. It should be at least sixteen inches in 
length. A " nest " of smaller trays for solutions, sponges, small instru- 
ments, etc., is very useful. 

A few aseptic dressings, cotton, gauze, and the like, for emergency 
cases are indispensable ; sterile tape, narrow and strong, for tying the cord 
should not be forgotten. This latter is usually not at hand when wanted. 

Laparotomies are best performed in hospitals when this is practicable, 
but he who does much obstetric work should have a laparotomy outfit 
accessible for emergencies and consultations. 

Nowadays it is not often found necessary to use the destructive instru- 
ments, but they should be at hand for emergencies, e.g., perforation of 
the after-coming head. The instruments ordinarily needed are the 
perforator of Blot or Simpson, and the cranioclast of Braun. 

\Miile it is not necessary to carry all the things sometimes recom- 
mended, those which are really essential should never be left at home. 
This is especially true of country practice, in which the physician must 
often be far from home and from other physicians. How unfortunate, 
how tragic indeed, to be unable to empty a distended bladder, or to be con- 
fronted with a case of postpartum hemorrhage, and to have no appliances 
for giving a hot douche or for packing the uterus ! 

Finally, the physician should provide himself with a bag large enough 
easily to contain what is necessary. The bags carried by many men are not 
more than half large enough. 

Preparations at the Home of the Patient.— In obstetrics it is the un- 
expected that happens, and one should strive always to be ready for 
emergencies. So far as the patient is concerned, however, it is best to do 
this quietly and not in such a way as to excite undue apprehension on her 
part. 

There is a tendency nowadays to overdo this matter of preparation. 
Nothing is more foolish than to surround a young woman awaiting her 
first confinement, with watchful nurses, and to convert her bedroom into 
a combined pharmacy, sterilizing plant, and instrument cabinet. All this 
pedantic and unnecessary parade leads her to believe that some formidable 
operation is in contemplation, or that the whole matter is much more serious 
than is usually the case. At all events, it is well calculated to fill her mind 
with morbid reflections. 



142 PREGXAXCY, LABOR AND THE PUERPERIU^I 

The room should be the largest, sunniest, cleanest, and best-ventilated in 
the house, although in midsummer it may be wise to select a room with 
northern exposure. One or two chairs and a table for drugs, instruments, 
etc., will be needed ; otherwise, the less furniture the better. Carpets, 
rugs, and unnecessar}- draperies should be removed, not because they are 
a direct source of infection, but because the room and ever\'thing in it, 
including hands, trays, and instruments, can be kept cleaner in an 
atmosphere free from dust. 

What should the nurse be instructed to have at hand? First of all, 
materials for disinfection and the preservation of asepsis. These should 
include lysol, alcohol, an abundant supply of sterilized gauze, sterilized 
absorbent cotton, and sterile towels. Sterile tape for tying the cord 
should be in readiness, and it is well to have on hand eight ounces of a 
saturated solution of boracic acid to be used for the child's eyes and for 
the nipples, since it takes some time to prepare this solution. A fountain 
syringe, clean and new, should always be at hand, or, still better, a douche 
can of white enamel with rubber tubing. ]\Iost of the so-called " confine- 
ment outfits " now sold are too expensive for the majority of patients, and 
contain many things that are quite unnecessary, or that can be improvised 
without trouble by any intelligent nurse. 

The Bed. — This should not be too low and should be accessible from 
both sides. It should be covered with a firm mattress. Feather beds and 
similar contrivances are an abomination. An ironing board or still better 
a table cover under the mattress, prevents the patient from sinking down 
into a hole in the middle of the bed, a great inconvenience in domestic 
practice. The arrangement of sheets and draw sheets is usually best left 
to the nurse, but there is one thing which should always be provided and is 
usually lacking, namely, a piece of rubber sheeting large enough not only 
to cover the whole bed but to hang well below the edge of the mattress on 
both sides. White oil cloth makes a cheap and convenient substitute. 
Newspapers beneath a clean sheet make a very useful protection in an 
emergency. Even in the household of the well-to-do the piece of rubber 
sheeting provided for the protection of the mattress is almost invariably too 
small and the result is disaster. 

Preparation of the Patient Herself. — During the last week or two of 
pregnancy care should be taken to secure a daily movement of the bowels by 
diet and the occasional use, if necessary, of a mild laxative like cascara or 
the citrate of magnesia. Castor oil, of course, should not be given unless 
it is desired to induce labor. In that case it should be the first step. Sexual 
intercourse should be prohibited. Xot only is it an unnatural and repulsive 
practice at this time, but it may be the means of infection or of hemor- 
rhage. I have known it to cause fatal bleeding in placenta prsevia, and 
Williams reports a case in which it was the cause of a severe infection. 

A daily bath with frequent washing of the vulva and adjacent parts 
with soap and water is to be advised. The pubic hair may be cut close with 



THE MANAGEMENT OF LABOR 143 

scissors, but shaving the parts in normal labor is quite unnecessary. 
Indeed by scraping away the epithelium and making many small cuts and 
abrasions it is more likely to produce than to prevent infection. This, of 
course, does not apply to cases in which an immediate incision is to be made 
as in pubiotomy. Douches are quite unnecessary and more likely to do 
harm than good. 

Preparations at the Beginning of Labor. — As soon as the pains 
have become well established the patient should receive an enema of a pint 
of soapsuds with a teaspoonful of turpentine. This often materially aids 
the progress of labor and contributes to cleanliness in the second stage. She 
should then receive a complete sponge bath of soap and water while stand- 
insf in the tub. It is not wise for her to sit down at this time since the bath 
water may and often does enter the vagina, especially in multiparse. After 
the bath the patient is attired in a clean night dress, with clean stockings 
and slippers, the vulva is covered by a pad of sterilized gauze, and she is 
allowed the freedom of her room. 

So much for preparation. Let us now take up the management of 
actual labor ; perhaps the most important task that falls to the lot of the 
physician. 

In a general way the duties of the attendant in a case apparently normal 
may be summarized as follows : 

1. To prevent infection. 

2. To attend to the general hygiene of labor, which includes attention to 
the bladder and bowels, to diet, stimulation, medication, moral encourage- 
ment and similar matters. 

3. To keep himself informed as to the condition of the foetus. 

4. To prevent perineal laceration. 

5. To supervise the third stage with special reference to the prevention 
of hemorrhage, and the complete expulsion of the placenta and membrane. 

The Prevention of Infection. — The general subject of the prophylaxis 
of infection is considered in the section on puerperal infection. We will 
consider here the specific measures to be adopted in normal labor. This is 
best done under two heads. 

1. The disinfection of the physician, patient, and accessories (instru- 
ments, dressings, etc.). 

2. The limitation of internal examinations and manipulations. 
Disregarding the remote possibility of auto-infection it is evident that 

puerperal infection is introduced from without. There is one instru- 
ment that must be frequently used and that cannot be perfectly disinfected 
— the hand of the physician. It is evident that the question of hand dis- 
infection is of prime importance. There has been much discussion as to 
what is the best method. Perhaps there is no best method. Reports of 
good results by different methods seem to indicate that success is due not 
so much to the particular chemicals that are employed as to the thorough- 
ness with which the method, whatever it may be, is carried out. The 



144 PREGNANCY, LABOR AND THE PUERPERIUM 



method which I personally prefer is a modification of that of Fiirbinger, 
and is as follows : 

The nails are first carefully cleansed of all visible dirt, should such 
unhappily be present, and the hands and forearms are then thoroughly 
scrubbed with hot water and sterile brush for five minutes by the clock, 
special attention being given to the nails, and to the sides of the fingers, so 
often neglected. Running water is always preferable. If this is not avail- 
able the water should be frequently changed. The hands are then thor- 
oughly dried with a sterile towel, and washed for five minutes in 80 per 

cent, alcohol, and later for five minutes 
more in a i-iooo bichloride or a one 
per cent, lysol solution. The bichloride 
solution often causes an eczematous 
condition of the hands which makes 
them more difficult of disinfection, and 
for many years I have been in the habit 
of substituting for it a one per cent, 
solution of lysol with excellent results. 
This has the advantage of being lubri- 
cant and thus making examination 
easier for the patient and less likely 
to produce abrasions of the mucous 
membrane which, themselves predispose 
to infection. Vaseline and similar 
unguents should not be used. It is so 
difficult to render them sterile and 
almost impossible to keep them so. 
Painting the roots and margins of the 
nails with tincture of iodine, as shown 
in Fig. no, is an additional precaution. 
Various writers have secured good re- 
sults with other methods which it is not 
necessary to describe here. One thing 
should be carefully noted, however, that all good methods have one 
feature in common, viz., prolonged and thorough scrubbing of the hands 
with soap and water. This I believe to be the most important part of the 
whole process. Macroscopical or gross cleanliness is the essential feature 
of hand disinfection. Alcohol probably contributes to this end. Chemical 
disinfection is an additional safeguard never to be forgotten, it is true, 
but on the whole less important. 

Let no one imagine then that should he, in some emergency, happen to 
be without chemical disinfectants he need necessarily despair. Wherever 
soap and water are to be had in abundance a large measure of success is 
obtainable. 

Conversely there is little or no benefit to be derived from the immersion 




Fig. 1 10. — A drop of tincture of iodine 
applied to the subungual region extends 
readily to the parts so difficult to disinfect. 



THE ^lAXAGEAIENT OF LABOR 



145 



in antiseptic solutions of hands that are not macroscopically clean. Chem- 
ical disinfection is not to be regarded as a fetich. A man who imagines 
that, by dipping a pair of not over clean hands in bichloride solution, he 
confers upon his patient immunity from the risks of internal examination 
is a dangerous man. 

The best method of all, however, for avoiding contact infection is the 
wearing of rubber gloves (Fig. iii). With these we reach the acme of 
safety. Every accoucheur should have one or two pairs in his bag 
sterilized and ready for use. In general practice, where facilities for steam 
sterilization are lacking, they can always be sterilized by boiling and drawn 
on with the aid of lysol solution. In emergencies, e.g., hemorrhage, they 





Fig. III. — Top, hand with usual variety of glove; bottom, long glove (gauntlet variety). 



are absolutely invaluable. The gauntlet variety affords the greatest 
security. Whenever there is time, however, the hands should be thor- 
oughly disinfected before putting on the gloves since the latter may tear or 
may be soiled in being put on. For obstetrical use it is not necessary that 
they be of the paper-thin variety. They may with advantage be somewhat 
thicker, in which case they are less likely to tear and need not be so often 
renewed. 

Dipping the gloved finger or hand in lysol facilitates its introduction 
enormously. In my experience there is but one condition in which the 
glove interferes with the operator's sensation of touch. One cannot always 
tell whether the membranes are ruptured. If there is a projecting pouch of 
membranes, as during a contraction, it is of course easy. When, however, 
10 



146 PREGNANCY, LABOR AND THE PUERPERIUM 

the membranes are closely applied to the child's head with no intervening 
fluid, as is sometimes the case, their recognition is difficult. This, however, 
is not usually a matter of great importance since one can wait for a 
contraction or provoke one by artificial means. 

DisixFECTioN OF INSTRUMENTS AND APPLIANCES. — Whatever instru- 
ments or appliances enter the genital canal should be sterilized by heat. 
This applies not only to steel instruments but to all others. Rubber 
catheters can be boiled, rubber bags will stand several boilings, and so will 
fountain syringes and rubber tubing. There is no place so poor that fire 
and water are not to be had, and an instrument boiled for twenty minutes 
over the kitchen stove is as sterile as though ft had been through all the 
laboratories in Christendom. Receptacles employed for sterilizing should 
hold enough water to cover the instruments contained. The very common 
practice of boiling the blades of the forceps but not the handles is not to 
be commended. 

-r- Nor need we be without sterile dressings. Towels, napkins and sheets 
can also be boiled or if there is no time for this can be taken fresh from the 
laundry and wrung out of lysol or bichloride solution. 

Experience has convinced me that with care good results can be 
obtained amid surroundings that seem most unfavorable. 

Some men seem to think that unless the patient is in a good hospital or 
in a comfortable home under the care of a skilled nurse asepsis cannot be 
attained, and efforts in this direction are a waste of time. This is a foolish 
and disastrous mistake, and has doubtless cost the lives of many women. 
The two great essentials for aseptic management of a case are plenty of 
soap and water and a good fire for boiling. Fortunately these can be had 
anywhere. A bottle of lysol or a few tablets of bichloride, a pair of gloves, 
a little extra time and attention — what are these in comparison with the 
safety of the patient and the added satisfaction of a clear conscience? 
Not to speak of a lower object but one by no means to be despised, freedom 
from criticism. 

Disinfection. — The finger of the accoucheur may be sterile or as 
nearly so as it is possible to make it, and it may be clothed in a rubber glove 
that is absolutely sterile, but it cannot be introduced into the vagina without 
contact with the external genitals. Here we have another source of in- 
fection. The external parts are not free from bacteria and these may 
be carried into the vagina by the examining finger. True the danger is not 
great. Virulent organisms are not usually present upon the genitalia of 
healthy women. If they were, infection would be much more common 
than it is. But even though the danger be slight, it exists, and no possible 
source of infection should be disregarded. The matter is too serious. 
How then are we to prevent the transmission of infection? 

1. By disinfecting the vulva. 

2. By limiting the area of contact. 

The disinfection of the vulva is accomplished as follows : The patient 



THE MANAGE:\IENT of labor 147 

is placed in the dorsal position with the knees widely separated and the 
sterile napkin that was applied after her bath is removed, the attendant 
disinfects his hands, and the parts are thoroughly scrubbed and irrigated 
from above downward, with lysol or bichloride solution, by means of 
sponges of sterile absorbent cotton which have been soaking in the solution. 
Thus the fingers need not come into contact with the parts. If the hands 
have become contaminated they must now be redisinfected. The operator 



A 



^x V 



\ 





\ 



Fig. 112. — Patient prepared for pelvic examination. 

now dons a pair of sterile rubber gloves and proceeds with the examination 

(Fig. 112). 

Contact with the external genitals is limited as much as possible by 
widely separating the labia during the introduction of the fingers and by 
keeping the latter exactly in the median line. 

Limitation of Internal Examinations. — But there is something else ta 
be remembered in the prophylaxis of infection. Infection comes from 



148 PREGNANCY, LABOR AND THE PUERPERIUM 

without and although we can attain a high degree of safety by the measures 
already outHned this safety is not absolute. Labor is a process extending 
over hours, or perhaps days. It is too much to expect that sources of error 
or lapses in technic will never occur or that accidental contamination is 
always avoidable. It is perfectly plain, then, that we should avoid all 
internal examinations that are not absolutely necessary. 

Unfortunately this fact is not generally appreciated. It is still the 
custom with many physicians to proceed at once with vaginal examination 
as the first step in every case of labor. This is a mistake. In the first stage 
of labor one can learn much more from external than from internal 
examination. I have never had any difficulty in convincing my students 
of this fact in one or two lessons. Internal examination may or may not 
be necessary to correct or supplement the result of the external. Very fre- 
quent internal examinations are never necessary. 

The methods employed in the external examination of pregnancy have 
been considered in connection with the antepartum examination. Palpa- 
tion, of course, is not feasible during contractions, and at the height of a 
contraction the fetal heart sounds may become inaudible. During the 
intervals, however, both auscultation and palpation are usually feasible. 
Some patients are sensitive and hard to control at this time and the physi- 
cian cannot work with the same leisurely care and thoroughness as at the 
antepartum examination ; but brief anaesthesia will remedy all this. 

By external examination one can determine the position of the head, 
whether above or below the brim, at the inlet or at the fundus, can follow 
the descent and rotation of the shoulder, and can keep himself informed 
as to the location and character of the fetal heart sounds. A knowledge of 
all or any of these things may, in a critical case, be of priceless value. 

A little practice will suffice to show that internal examinations can be 
much restricted and in some cases avoided altogether. If the physician 
will study the external diagnosis of pregnancy with the same care that he 
bestows upon the physical diagnosis of cardiac and pulmonary diseases he 
will soon become able to limit the number of internal examinations to a 
minimum, and in many cases to do away with them altogether. To speak 
personally, I have found that I can get much more information from the 
external examination than from the internal. 

There is a large proportion of cases in which it is perfectly plain to any 
thinking man that vaginal examination is quite unnecessary. Every prac- 
titioner knows from experience that unless he responds promptly when 
called to attend a multipara he is likely to be too late and yet if he does 
arrive in time he usually makes one or more such examinations, if only as a 
matter of form, even though it is perfectly plain that the patient is far 
advanced in the second stage and will soon be delivered. 

Let us take a typical case. The patient has had several children before 
and her labors have been easy. The membranes have ruptured and the 
pains are becoming expulsive in character. 



THE AIANAGEMENT OF LABOR 149 

Palpation shows that the head is in the pelvic cavity and that the 
shoulder is only an inch or two above the symphysis. The patient's general 
condition is good, the fetal heart sounds are strong and regular, the vaginal 
outlet is capacious. Such a case needs no vaginal examination and 
infection is almost impossible. 

The great majority of cases seen by the general practitioner are cases 
of normal labor in multipar?e and would get along perfectly well without 
any active interference whatever. J\Iany of them when first seen have 
passed the time for most complications, and it is certainly deplorable that 
such cases should become septic through unnecessary manipulations. 

But all cases are not of this kind and we must admit in general practice 
that many patients require vaginal examination for one reason or another. 
Palpation is not available in very stout w^omen. The physician's time is 
limited and he cannot watch his cases from beginning to end as can the 
resident staff of a maternity hospital. Moreover there is no doubt what- 
ever that vaginal examination is far safer than it was before the 
introduction of rubber gloves. 

Since, then, vaginal examination must be practised to some extent how 
should it be limited ? The question is not a simple one, and the answer will 
vary with the skill acquired in external examination. If external ex- 
amination has shown position and presentation to be normal, no pelvic 
contraction, and if in the case of a primipara the head is well down in the 
cavity of the pelvis, or if in the case of a multipara previous labors have 
been easy, vaginal examination is unnecessary or at least there is no 
occasion for haste. 

Repeated examinations during the first stage are unnecessary, though 
they may be desirable in some cases as helping to determine the progress 
of labor and enabling the physician to estimate its probable duration and 
to tell whether or not it is necessary for him to remain with the patient. 
As a general rule it is neither necessary nor desirable that the physician 
should remain with his patient during the entire first stage. In the case 
of a multipara, however, it is not wise for him to be far away after the 
cervical canal has become effaced and the os dilated to the size of a half 
dollar. In a case like this the resistance of cervix, vagina, and perineum 
has been overcome in previous labors and rupture of the membranes may 
be followed by a second stage of short duration — sometimes only a few 
minutes. In a primipara, however, cervical dilatation is much slower, and 
hours may be required to overcome the resistance of the vagina and 
perineum. It is usually safe, if a good nurse is in attendance, for the 
physician to absent himself for some hours, leaving word with the nurse 
to caU him if well marked second stage pains should develop. 

The physician is often asked as to the probable duration of labor. His 
reply should be cautious and conditional if he would keep his reputation 
as a prophet. 

But to return to the question of repeated examinations during the first 



150 PREGNANCY, LABOR AND THE PUERPERIUM 

stage. It has been said, and I think with truth, that in the average case 
there are only two things that cannot be learned by external examination, 
ins., the degree of cervical dilatation and prolapse of the cord ; but if labor 
is apparently progressing normally and if external examination shows that 
the head is descending it is pretty safe to say that the cervix is dilating and 
it hardly seems necessary to demonstrate this by measures that are 
prejudicial to the welfare of the patient. Moreover, there is little or no 
danger to the child before rupture of the membranes, and we can assure 
ourselves of its safety by auscultating the fetal heart at intervals. 

Naturally more solicitude is felt in the case of a primipara than in that 
of a woman who has already borne a child at term, provided the latter has 
no history of difficult labor. According to the statistics of Matthews 
Duncan the liability to complications diminishes progressively after a first 
labor, until the ninth. 

As the head advances the difficulty of examination becomes less, but in 
normal cases it can hardly be said that the necessity of examination becomes 
greater. There is, of course, no doubt that the ability to recognize 
promptly a delayed first stage, and the cause of delay, is of the highest 
importance and in doubtful cases the accoucheur should not allow undue 
timidity to prevent him from clearing up all doubt by thorough and careful 
investigation, under ether if necessary. On the other hand, however, he 
should carefully avoid falling into habits of indolent routine, and should 
perfect himself in every extravaginal method of diagnosis which may save 
his patients from examinations and manipulations that are not only 
unnecessary but at times dangerous. 

There is no doubt that certain unfavorable conditions, e.g., face and 
brow presentations, prolapse of the cord or of an extremity, are favored by 
rapid escape of the amniotic fluid, and there is perhaps some reason for 
making a vaginal examination immediately after rupture of the membranes. 
This will also determine the fact of their premature rupture, an accident 
which makes careful subsequent observation of the case imperative. 

The necessity for frequent examinations during the second stage is 
not apparent, especially if examination after rupture of the membranes 
shows no abnormality. The changes in the size and shape of the 
abdominal tumor tell that the head is low in the pelvis and the experienced 
observer learns much from the demeanor of the patient and the character 
of the pains. 

It would be interesting to pursue this subject at length if space per- 
mitted. Suffice it here that a brief study of the chief objects to be 
attained by vaginal examination will show that its employment in normal 
labor is too common. 

Two things are certain: i. If the physician can remain with his 
patient, little or no examining is necessary in normal cases ; and 2. The 
more the physician perfects himself in the external examination of 
pregnancy the less need will he have for internal examination. 



THE MANAGEMENT OF LABOR 151 

There is an unfortunate disposition among students and practitioners 
to regard diagnosis by external examination as an impracticable refine- 
ment or at least as something to be reserved for obstetric specialists. This 
is a great mistake. It is just as easy and of far greater practical use than 
much of the physical diagnosis that is taught in the schools as part of the 
course in general medicine, and it is absolutely necessary to the intelligent 
practice of obstetrics. 

Technic of Vaginal Examination During Labor. — If the head is in 
the cavity of the pelvis the simple introduction of one finger may suffice. 
If it is at or above the brim two fingers will be required. The labia being 
-widely separated by the fingers of one hand two fingers of the other are 
carried into the vagina. If the introitus is small, their introduction is 
favored by gentle backward pressure against the perineum, but it is well 
to avoid contact with the anus by keeping it covered by a sterile towel. 
The introduction of the fingers should be very slow and gradual, and the 
hand should be gloved and well lubricated with lysol solution. Nothing 
else makes introduction so easy. These precautions are well worth re- 
membering. Rough and hasty work here is not only indelicate and cruel, 
but it alarms the patient, destroys her confidence in the physician, and fails 
to secure results. Gloves should be worn for three reasons. They 
diminish the danger of infection, and when well lubricated with lysol 
greatly facilitate the easy and painless introduction of the fingers. Last 
but not to be forgotten they may save the attendant from criticism. 

What is to be determined by this examination ? 

The character of the presentation, the relation of the presenting part 
to the pelvic brim, the capacity and distensibility of the vagina and its 
outlet, and the capacity of the pelvis, not forgetting the length and 
inclination of the symphysis and the character of the symphyseal angle. 

Methods of pelvimetry are discussed in the section on pelvic contrac- 
tion. As in the antepartum examination, however, it will not be necessary 
to compel every patient to submit to a careful internal pelvimetry. For 
example, in the case of a multipara with a history of easy labors, such a 
procedure would obviously be superfluous. In most primiparse the head is 
well down in the pelvic cavity at the beginning of labor, and here, too, 
nothing is necessary except to measure the pelvic outlet. Further the 
practitioner who uses modern methods will, in the case of his own patients, 
have already made himself familiar with the pelvic dimensions. 

If, however, the patient is a multipara with a history of difficult labor, 
or if in the case of a primipara, the head is above the brim and cannot be 
made to engage by external pressure, a careful estimate of the pelvic 
capacity must be made. If the patient be a primipara or if she be very 
sensitive a light anaesthesia will not only make the procedure painless but 
w^ill facilitate the examination in a high degree. 

One should never forget to measure or at least estimate the pelvic out- 
let, since this causes the patient no pain and is excellent practice for the 



152 PREGNANCY, LABOR AND THE PUERPERIUM 



physician. Moreover, outlet contraction is often overlooked, the observer 
taking it for granted that all is well because he finds the head in the cavity 
of the pelvis. 

(As a rule position and presentation can be determined more easily 
by external examination, if the practitioner " knows his obstetrics.") 
The rules for the diagnosis of the various malpositions and malpresenta- 
tions are given elsewhere. The hard globular vertex can be mistaken for 
nothing else. In the centre one feels the sagittal suture running trans- 
versely or obliquely across the field. In the ordinary L. O. A. position it 
runs obliquely and the small fontanelle is found at its anterior extremity, 
i.e., somewhat anteriorly and to the left. From this fontanelle run three 




Fig. 113. — Digital examination in vertex presentation, L. O. P. Right hand follows sagittal suture 
and approaches the small fontanelle. 

sutures, the sagittal and the two lambdoidal. During labor this so-called 
posterior fontanelle does not constitute an opening, a fact which often 
puzzles the beginner. The force of the uterine contractions causes the two 
parietal bones to override the occipital, and in the place of the fontanelle 
one feels the apex of an angle formed by the meeting of two ridges of bone 
which correspond to the two lambdoidal sutures. Backward and to the 
right is the large, anterior fontanelle, from which run four sutures; the 
frontal, the sagittal, and the two frontoparietal. This fontanelle is never 
closed, and gives the examining finger the impression that it is much softer 
and more depressible than the posterior. When the head lies transversely 
the sagittal suture will also be transverse and the fontanelles will be found, 
one at either side of the pelvis. AMien the occiput is posterior the position 
of the fontanelles is reversed, the small fontanelle being posterior, and the 



THE IMANAGE^IENT OF LABOR 153 

large one anterior. \\'hatever the position of the head, if the small fon- 
tanelle is markedly lower than the large one the head must be well flexed, 
while if the two fontanelles are on the same level the head is moderately 
-extended (Figs. 113, 114 and 115). It is usually easy to recognize the 
sutures and fontanelles in the second stage of labor, when the head is low 
in the pelvis, and the cervix fully dilated, and the beginner should lose no 
opportunity for this kind of practice. 

As a rule it is not justifiable to invade the cervix simply to locate the 
sutures and fontanelles and thus verify the diagnosis of position, or for the 
sake of practice in diagnosis. This procedure, too common among students 
and hospital internes, not only causes considerable pain, but materially 
increases the risk of infection, and all this without yielding any corre- 




FlG. 114. — Vertex presentation, R. O. A. Left hand follows sagittal suture and 
reaches the small fontanelle. 

sponding benefit to the patient. It may not be out of place to recall here 
the well-known, but too often forgotten, fact that the danger of sepsis is 
distinctly increased when the finger is carried within the cervix or into the 
lower uterine segment, where the acid vaginal mucus no longer aids in 
inhibiting bacterial development. The man who finds it necessary fre- 
quently to resort to painful and dangerous methods of examination has 
not yet learned the principles that underlie management of normal labor. 

If delayed labor with threatening symptoms makes an exact diagnosis 
-necessary, and, owing to the height of the fetal head, the thickness of the 
abdominal wall, the absence of the fetal heart sounds, or a large caput 
succedaneum, the diagnosis of position by the usual methods difficult or 
impossible, it is better to give the patient a little ether and, if necessary, 
introduce the half hand. The patient is now relaxed and difficulties 
disappear. A most useful guide in these cases is the posterior ear. This, 



154 PREGNANCY, LABOR AND THE PUERPERIUM 



of course, points in the same direction as does the occiput. But more of 
this when we come to the study of delayed labor and especially of posterior 
positions of the occiput. 

Before making this final examination it is well to make every prepara- 
tion for an eventual operation in order that, should the latter prove desir- 
able or necessar)', it may be performed at once and the patient saved the 
inconvenience and danger of added manipulation and repeated anaesthesia. 

So much then for the prevention of infection, the most important part 
of the management of labor. But this is not all. There are certain general 
measures which experience has shown to be beneficial. 



Conduct of the First Stage 
The patient should not be put to bed during the first stage. 



As a gen- 



ROP 



ROA 




LOP 



LOA 



Fig. lis. — Diagram showing position of the small fontanelle in relation to the superior strait. 

eral rule she prefers to be upon her feet and it is far better that she should 
be. The upright position favors engagement of the head and dilatation 
of the cervix. This fact has been amply demonstrated by experience. 
There are. however, certain exceptions to this rule, e.g., in breech presenta- 
tions and in contracted pelvis, premature rupture of the membranes is 
especially unfavorable, and at the same time especially likely to occur, and 
for these reasons it is wise to keep the patient quietly in bed. The same 
precaution is obviously necessary in placenta praevia and in prolapse of the 
cord. If labor begins at night and the patient shows a tendency to sleep 
between the pains she should, of course, be allowed to sleep, since a sleepless 
night is a very poor preparation for the ordeal that is to follow. 

The patient should not make any hearing dozvn efforts during the first 
stage. She is often advised by ignorant nurses or bystanders to bear down. 
Such advice is bad. The contractions of the first stage are contractions 
of the uterine muscle, involuntary muscle, be it remembered, and are 



THE MANAGEMENT OF LABOR 155 

entirely independent of the will. Expulsive efforts can only result in 
needlessly tiring the patient and perhaps in causing premature rupture of 
the membranes. 

Attention to the Rectum and Bladder. — A full bladder is a serious 
obstacle to the progress of labor since it prevents uterine contraction. The 
patient should empty the bladder every two or three hours, and the physi- 
cian should satisfy himself by palpation that the bladder is empty. The 
statements of the patient or the nurse can never be depended upon in this 
respect. This is usually due to the fact that the parts are benumbed 
from pressure. Then, too, the escape of liquor amnii is often mistaken 
for the passage of urine. A full rectum tends to inhibit uterine contractions 
but not to the same extent as does a distended bladder. It is also a 
mechanical obstacle to delivery. The soapsuds and turpentine enema 
should be given if this has not already been done, using only a vessel that 
has recently been cleaned and scalded. After each emptying of the bladder 
or rectum the vulva should be carefully cleansed from before backward 
with lysol solution and a fresh dressing applied. 

Psychical influences play an important part in the management of the 
first stage of labor, and in the process of cervical dilatation. During the 
second stage, and especially after the rupture of the membranes, the reflex 
influence to bear down is usually imperative and not to be resisted, but in 
the first stage much depends upon suggestion and mental influence. This 
soon becomes known to every observant physician. The quiet and orderly 
progress of the first stage of labor is favored by leaving the patient alone, 
i.e., with only the attendance and companionship of a sensible and compe- 
tent nurse. There are times when the absence even of the physician is of 
more service than his presence. Curious and officious people should be 
banished from the room or, better, from the house. Overexcited relatives 
usually do more harm than good. 

In every long and painful first stage some effort should be made to 
alleviate the sufferings of the patient, and this should be regarded as an 
important part of the treatment. There is neither sense nor science in 
permitting the patient to suffer more than is necessary. Moreover, the 
agents that reduce pain also cause relaxation of the cervix and thus actually 
shorten the first stage of labor. Of these agents chloral has always been 
a favorite with me. Unlike the '' twilight " treatment it has no tendency to 
prolong the second stage. Fifteen grains, well diluted, are given as soon 
as the pains become severe. This drug is sometimes irritating to the 
stomach and in this case may be given in double dose by the rectum. It 
does not abolish the pain but diminishes its severity, the patient often 
sleeping in the intervals. Morphine has a similar effect, but is more likely 
to narcotize the foetus, a result which I have not observed with chloral. 
If one prefers the morphine-hyoscine combination, ^ gr. of morphine may 
be given with 1/150 gr. hyoscine, the latter but not the morphia being 
repeated in from one-half to three-quarters of an hour. I do not, as a 



156 PREGXA^XY, LABOR AXD THE PUERPERIUM 

rule, advise the continuance of the morphine and hyoscine during the 
second stage, except under special and expert supervision. We will come 
to this subject again in connection with obstetric anaesthesia. I wish to 
emphasize here my utter rejection of the idea that pain is a necessary or, 
so to speak, a conservative force in labor. A woman may have contrac- 
tions that are not efficient though very painful, and again she may have 
powerful and efficient contractions without excessive pain. The idea that 
pain is to be, as it were, encouraged, was born long ago of ignorance and 
fanaticism and dies hard, but it is perfectly plain that contraction, not pain, 
is the essential element in labor. 

Anaesthesia. — Wt may assume, I think, that the patient under ordinary 
circumstances does not need and should not have anaesthesia during the 
first few hours of the first stage. Pain at this time is not unbearable. 
]\Ianv indeed there are who would decry the attempt to give the patient 
relief during any part of the first stage. This depends, I beheve, upon the 
prevalent but erroneous idea that pain in labor increases progressively in 
severity from the beginning of the first to the end of the second stage. As 
I have tried to show, in connection with the clinical history of normal labor, 
the greatest sufii'ering. with the exception perhaps of that which is experi- 
enced during the final act of expulsion, is experienced at and shortly before 
the period of full dilatation of the cervix. AA'hen we recall rhat this can 
be greatly mitigated by the administration of a few drops of ether with 
each pain, and this with little or no risk, humanity seems to demand that in 
aggravated cases we afi^ord the patient this measure of relief. This method 
can be employed when the physician is not called until the patient is far 
advanced in the first stage. Fifteen or twenty minutes of intermittent 
administration is a great relief to the patient at this time and helps her to 
bear better the ordeal of the second stage. 

\A'hen the physician sees his patient at an early stage of labor he may 
administer some analgesic by the mouth or rectum. 

In the second stage, chloroform is still a favorite with many practi- 
tioners who hold that in competent hands it is a safe and convenient agent 
for primary anaesthesia during the pains and pushed to the surgical degree 
for a few moments only, during the last act of expulsion. There can be no_ 
doubt that women in labor enjoy a remarkable degree of immunitv from 
the toxic efifects of chloroform. 

Despite its popularity and undoubted convenience, I have gradually 
become convinced of the superior safety of ether not only in obstetrical 
operating but also in the primary anaesthesia to which we so often resort for 
the alleviation of the " pains "' of the latter part of the second stage in 
uncomplicated labor. For the latter purpose it is best given on an ordinary 
chloroform mask and in drop doses and when properly administered the 
physiological efi:"ect of the ether supplementing the cerebral congestion 
which attends the bearing down efiforts is such that analgesia may be in- 
duced by the use of an incredibly small amount of the drug. 'Mv experi- 



THE MANAGEMENT OF LABOR 157 

ence has taught me that chloroform, even in small doses, causes more or 
less uterine relaxation and postpartum oozing. 

Nitrous Oxide-oxygen. — This gas, used by obstetricians some forty 
years ago, has recently come into favor again. In the hands of an expert 
anaesthetist it has proven harmless in the great majority of cases, and with 
apparatus recently perfected is well adapted to routine hospital practice. 
Its use is indicated, like that of ether, as an analgesic, when the first stage 
is far advanced, given only with the pains, and later for complete anaesthe- 
sia as required. Nitrous oxide-oxygen does not retard labor, but rather 
stimulates uterine contractions. The misuse of this gas has caused rapid 
asphyxiation of the foetus. Oxygen must be liberally supplied, the relative 
quantities of the gases being varied according to the character of the pains. 
Instances in which this method is particularly applicable are noted 
elsewhere. 

" Twilight Sleep." — There has been much heated discussion about the 
value and the dangers of twilight sleep. Undue conservatism has opposed 
it, as it always opposes everything that is new. Unhappily, something of 
the stupid and cruel superstition that suffering during labor is in itself 
beneficial still lingers in the minds of many. 

On the other hand, an overzealous and often unintelligent advocacy 
of the method with an apparent determination to ignore its possible dangers 
and to resent legitimate and well-.meant investigation and criticism has 
done much to keep it out of the hands of those best qualified to judge as to 
its real merits. 

On one point all are agreed, vis., that the twilight sleep as practised at 
Freiburg, and as advocated by its chief exponents elsewhere, is not 
adapted to general practice, at all events, not unless the attending physician 
can remain constantly with his patient or can command the services of a 
competent assistant during his absejice. I strongly resent, however, the 
assumption that the average general practitioner is less qualified to manage 
these cases than the average general surgeon or gynaecologist. There are 
comparatively few of the latter who have the time or the inclination to 
devote long periods to the laborious and ill-paid work of pure obstetrics. 
The general practitioner is obliged to do this work whether he will or not, 
and his obstetric judgment, if I may use such a term, is usually far better. 

The thing which strikes the observer most forcibly is that the dose has 
been materially reduced, especially the amount of. opiate has been ma- 
terially reduced. The use of a reliable preparation of scopolamine is 
insisted upon at Freiburg. There are two difficulties in its preparation. 
It is not easy to isolate and if the work is not properly done various impuri- 
ties may be present. Then, too, solutions of the drug deteriorate easily. 
It is claimed at Freiburg that it will keep for years in a ten per cent, solu- 
tion of mannite, the so-called scopolamine Haltbar. One often hears the 
question from those interested in twilight sleep, " What is scopolamine? " 



158 PREGNANCY, LABOR AND THE PUERPERIUM 

It is nothing more nor less than hyoscine. The mannite solution keeps 
better. That is all. 

Narcophin (morphine-narcotin-meconate) has been much employed 
at Freiburg and elsewhere and is still on trial. Its advocates claim that it is 
less toxic than morphine and equally efficacious. Apparently this has not 
as yet been proven. 

As far as my experience goes I have not found that the treatment in- 
jures the mother. A certain small proportion seem to have an idiosyncrasy 
against the drug. They become excited and even maniacal and are difficult 
to restrain or control. In these cases it may be necessary to give up the 
treatment since an aseptic management of the case becomes impossible. 
The treatment certainly prolongs the second stage of labor and perhaps 
increases the number of low forceps operations, but this is counterbalanced 
by the fact that lacerations are rather less common. Contrary to my pre- 
conceived opinions and prejudices I am compelled to say that as far as my 
observations have gone uterine relaxation and hemorrhage are not more 
common than under other methods of treatment or when no analgesics or 
anaesthetics at all are used. As far as the toxic effects of the drugs are 
concerned I have seen no harm except perhaps in the case of the excitement 
mentioned above. There are certain factors which operate during labor as 
antidotes to the depressing effects of analgesics and anaesthetics. These 
factors operate in the case of scopolamine as well as in that of chloroform 
and ether. This is shown by the fact that in the one case, as in the other, 
a patient who has been more or less restless during labor falls into a pro- 
found sleep as soon as labor is over. On the whole I believe that the use 
of these drugs is less dangerous to the mother than is the reckless fashion 
in which I have often seen chloroform used. 

The darker side of the picture appears when we come to consider the 
effect of the treatment upon the foetus. In Gauss's series of 506 cases the 
fetal mortality was about two per cent., which, when we consider that they 
were all picked cases, i.e., that cases in which there was any reason for 
apprehending danger to the foetus were excluded from this list and that all 
the labors and deliveries were conducted by skilled obstetricians, seems 
rather high. We must not forget, too, the undoubted tendency of all 
observers, no matter how conscientious, unconsciously to interpret statistics 
as favorable to the cause which they represent. To take a single example, 
the contention that all danger to the child may be prevented by listening to» 
the fetal heart is absurd. Men differ in their ability to hear the fetal heart 
and interpret what they hear. If we do not begin delivery until we are 
satisfied that the foetus is actually in danger we may be too late. Moreover, 
there are cases in which for one reason or another the fetal heart sounds 
cannot be heard although the foetus is alive and vigorous. Hasty delivery 
under these circumstances may do serious and unnecessary harm. Dr. 
A. J. Rongy, who has had a large experience with the " twilight sleep," 
stated recently that he now uses the method much less than formerly, having 



THE iMANAGEMENT OF LABOR 159 

become convinced that it is attended by a distinct risk to the child. Many 
other advocates of the method lay great stress upon the necessity of 
constant watchfulness with respect to the welfare of the foetus. 

The morphine-hyoscine combination was first used in obstetrics by 
Steinbuchel, though it had been in use in general surgery since its advocacy 
by Schneiderlein, in 1899. In 1902 Steinbuchel reported his results in 
thirty-one cases, and his example was followed by various observers 
both in America and Europe. Notable among these were Cremer, who, 
in his monograph, Entbindung oluic Schmerzen, and other articles, re- 
ported 134 cases, and Bertino, who reported 400 cases. Steinbuchel gave 
morphine gr. % and scopolamine gr. 1/200, repeating the dose in two 
hours and again, if necessary to produce the required degree of anal- 
gesia. In some cases he used as many as five injections. Even at this 
early date some of those who followed him seem to have discerned 
the fact that good results may be obtained with a much smaller dosage. 
Bertino reported a large number of asphyxiated children, though it 
must be admitted that the doses which he used were larger even than 
those of Steinbuchel. 

The method, or something Hke it, was practised and the results re- 
ported by many observers in this country, a semi-proprietary prepara- 
tion, the familiar H. M. C. (hyoscine, morphine and cactine) tablet, being 
used. The treatment, however, soon became unpopular, owing to the fact 
that "blue babies" and still births became alarmingly frequent. This fact 
I have abundant opportunity to confirm from the graduate students of the 
New York Polyclinic, who represent all sections of the country. 

Of course this purely empirical and rather haphazard method produced 
results varying with the physician's experience and judgment. If he 
•was wise enough to carefully restrict the size of the dose as well as the 
number of doses he secured a gratifying degree of analgesia without doing 
harm. But it was necessary to learn this by experience and it is to be 
feared that many a fetal hfe was snuffed out in the process. Neither in 
Europe nor America was any attention paid to the memory test nor were 
the dangers of overdosing generally recognized. " Twilight sleep," in the 
sense in which the term is now used, did not exist. 

It was not until 1906 that Gauss published the results obtained by a 
new technic devised by himself and designed to produce a sort of semi- 
narcosis which he christened by the happy term Diimmerschlaf. Not satis- 
fied with the diminution of suffering or even with prolonged periods of 
sleep he sought "to abolish all memory of pain. This he succeeded in ac- 
complishing in a large proportion of cases. Hellman has written a very 
clear and concise history of the subject. According to his own statistics 
a satisfactory amnesia was obtained in 76 per cent, of his cases and marked 
relief in 18.2 per cent. He gave larger quantities of the drug than are 
usually given nowadays, for example, in a case lasting over fifty-seven 
hours he gave 1/17 gr. scopolamine and )<2 gr. morphine. As a rule. 



160 PREGNANCY, LABOR AND THE PUERPERIUAI 

however, he found that no great increase in dosage is necessary to produce 
amnesia, but that it is rather a matter of giving the doses at the right time 
and of the careful appHcation of the memory test. He aimed to keep the 
patient in a condition in which, although she responds to direct questions 
and perhaps shows a reflex response to painful contractions, she has lost 
the power of remembering recent events. This is determined by calling 
her attention to recent events, for example, by showing her a watch w^hich 
has been shown her an hour before. In the condition which Gauss aimed 
to bring about, and, in a large majority of cases, did bring about, the past 
and future are alike a blank. The patient lives in the present alone, 
and as the present fades into the past it disappears never to return, not 
even in memory. This, of course, is more than analgesia or the mere 
relief of pain. It is analgesia plus amnesia; the relief of pain plus the 
obliteration of all recollection of the parturient process. Sometimes this 
state is easily produced. I recall the case of a patient who received % gr. 
of morphia and 1/150 gr. of scopolamine early in the first stage and 
forty-five minutes later 1/200 gr. of scopolamine with the result that she 
slept quietly until long after labor was over and upon aw^akening had no 
recollection whatever of what had occurred. Unfortunately, however, 
such an ideal result cannot ahvays be depended upon. There are many 
cases in which the desired amnesia can only be obtained by repeated doses 
of scopolamine and even by an additional dose of morphine. This, of 
course, requires careful, constant and expert supervision. Gauss and all 
subsequent workers in this have found that in order to succeed it is neces- 
sary to individualize the cases, watching each patient carefully and repeat- 
ing the dose and varying the dose, or preferably its frequency, according 
to circumstances. 

What are the effects of the treatment upon mother and child? Fifteen 
or twenty minutes after the first injection the patient usually becomes quiet 
and drowsy and after one or two subsequent injections the typical 
" twilight " condition is developed. The patient lies in a semi-stupor with 
flushed face and dilated pupils. She grimaces and moves about during a 
contraction. Here the suggestion of Hellman is very useful. If at the 
close of such a contraction the patient, in reply to questions, shows that 
she has no recollection of painful sensations, her degree of amnesia is 
regarded as satisfactory. It must be admitted that the appearance of the 
patient at this time is not such as to console her friends or to reassure the 
inexperienced attendant. In some cases her outcries and contortions are 
such as to convince anyone that she is really suffering acutely and yet after 
delivery she will declare that she remembers nothing at all of the affair. 
It will be impossible, however, to convince her immediate family of this if 
they are present during labor, and it is for this reason that Polak shrewdly 
advises that near relatives be excluded from the room. As the exclusive 
pains of the second stage become stronger the reflex response of the patient 
becomes greater and at the final moment of expulsion she may become 



THE ^lAXAGEAIENT OF LABOR 161 

quite uncontrollable, strangely enough requiring perhaps a few drops of 
ether to complete annihilation of pain and blotting out of memory. Some- 
times the patient awakes at this time and realizes for the moment what is 
going on and this so vividly that she remembers it afterward. This is an 
example of what are called in the picturesque terminology of Gauss, 
" Islands of memory." It is the aim of those who strictly follow the 
Freiburg technic to avoid these '' Islands of memory " or at least to limit 
them as far as possible, since Gauss claims that if they occur too often the 
patient is able to reconstruct from them the entire history of labor. 

What is the Freiburg technic as now practised? For the sake of fair- 
ness I condense the description from Hellman's monograph, quoting 
accurately but not verbatim. The first injection is given when the cervix 
has become dilated to the extent of two fingers and when, in the case of a 
primipara, the pains recur regularly every five or six minutes, in the case 
of a multipara, not less than every seven to eight minutes. It consists of 
morphine hydrochloride gr. Yx and scopolamine hydrobromide gr. 1/150. 
Xo more morphine is given, the succeeding injections consisting entirely of 
scopolamine, the usual amount being gr. 1/150. Forty-five to sixty min- 
utes after the first injection the succeeding one is given and subsequent 
injections are given at intervals of from thirty minutes to two hours, as 
determined by the memory test, which is applied every ten or fifteen min- 
utes, and by the condition of mother and child. The number of doses 
administered is said to be of less importance than their effect, Hellman 
finding that from three to seven are usually sufficient. The patient is kept 
in a darkened room. Dark glasses or a cloth over the eyes, and plugging 
the ears with cotton are helpful. The bladder must be carefully watched 
since the patient in her condition of semi-stupor may not recognize or 
respond to the ordinary stimulus of distention. Personally, I am of the 
opinion that the prolongation of the second stage so often observed is due 
in part to the neglect of this precaution. Moreover, as we have observed 
elsewhere, the use of the catheter is far more likely to produce infection 
after delivery than before. 

The practical question for us to consider here is, What have we learned 
from the Freiburg school? How far can this new knowledge be safely 
apphed in general practice? 

May I venture to summarize my opinions as follows : 

A very considerable degree of first stage analgesia may be realized 
through the employment of a very small quantity of morphine and 
hyoscine, a quantity so small as to be without danger to mother or child. 

Two doses are preferable to one since it has been clearly shown that the 
cumulative effect of a second very small dose of hyoscine produces better 
results than the administration of the entire quantity at one dose. 

Analgesia during the second stage is best produced by the administra- 
tion of ether by the drop method and only at the height of a pain. The 
II 



162 PREGNANCY, LABOR AND THE PUERPERIUM 

attendant should be content with partial anaesthesia at the height of pains 
except perhaps when the head is passing over the perineum. 

No attention is paid to the memory test, as no effort is made to secure 
amnesia. If no relief is afforded by the two injections, which is not often 
the case, no third injection is given. 

Of course, this is not twilight sleep. It is only a partial substitute, but 
it has the advantage of being safe and applicable to general practice and it 
certainly very materially diminishes the suffering incident to labor. In 
some of our cases at the New York City Hospital nothing more than the 
first two injections was necessary to produce analgesia so complete that no 
ether was required during the second stage, the patient awaking a few 
hours after delivery with no recollection of what had happened. 

The artificial rupture of the membranes as soon as the cervix is com- 
pletely dilated is advised by many writers. This is a grave mistake and one 
for which the inexperienced accoucheur has often had occasion to regret 
his teaching. There are certainly frequent occasions, especially in multi- 
parae, in which labor may be promptly terminated by artificial rupture and 
the patient thereby relieved of much unnecessary suffering, but for the 
decision experience and good judgment are required. The young and in- 
experienced physician will do well to be cautious in this respect. 

Nature's method of overcoming resistance to the progress of labor is 
by hydrostatic dilatation, and this is not finished with expansion of the 
cervix. The upper part of the vagina as well must be dilated and the head 
must be well down before the vaginal muscular coat can aid in expulsion. 
When the perfect physiological dilator is lacking lacerations are more 
frequent and sepsis more common, and how often, under anaesthesia, it 
is found that there is more of the cervix left than was supposed. 

Not only do the unruptured membranes help to dilate the upper vaginal 
segment, particularly in primiparae, and to prevent precipitate labor in mul- 
tiparae — they are a safeguard against infection, both by lessening the num- 
ber of lacerations and by flushing the vagina when labor is nearly complete. 

The loss of the amniotic fluid is followed by uterine retraction, sub- 
jecting the foetus to direct pressure and lessening its oxygen supply by 
diminishing the calibre of the placental vessels. This may render neces- 
sary an otherwise avoidable forceps operation to save an asphyxiated 
child. 

Conduct of the Second Stage 

As the second stage approaches it is better for the patient to lie down, 
thus reducing the danger of prolapse of the cord or of small parts which 
sometimes occurs when the membranes rupture. It is not necessary, 
however, for her to occupy the dorsal position constantly, as is so often 
urged. This is a pernicious practice and is often responsible for delay 
in the second stage. It is much better for the patient to lie upon her side, 
part of the time, and to change her position at will. If progress is slow it 
may be materially aided by having the patient lie upon the side opposite to 



THE IMANAGEMENT OF LABOR 



163 



that toward which the fundus is directed. Since the uterus usually 
occupies a position of right obliquity this will usually be the left side. The 
fundus then sinks toward the median line, the long axis of the uterus, 
becomes parallel with the long axis of the body, and the head is pressed 
directly downward in the axis of the birth canal, or rather of whatever 
part of the canal it may occupy. I have many times had occasion to 
verify the efficacy of this simple manoeuvre. In the rare cases of left 




Pig. ii6. — Head resting on left ilium. Entrance favored by patient lying on her left side, 

uterine obliquity the patient would, of course, lie upon her right side 
(Fig. ii6). 

If progress is slow the patient should be encouraged to brace her feet 
against some fixed object, at the same time pulling upon the hands of a 
bystander, a twisted sheet, or some one of the special devices employed 
for the purpose, meanwhile holding her breath and " bearing down/* 
During the intervals she should remain perfectly quiet, thus conserving- 
her strength for the next pain. 



164 



PREGNANCY, LABOR AND THE PUERPERIUM 



If labor is progressing rapidly it is better for her to remain in the 
dorsal position and to a\oid bearing down efforts, thus minimizing the 
dangers of jH-ecipitate labor. 

During the latter part of the second stage the pressure of the descend- 
ing head causes faeces to be expressed from the rectum. These should be 
carefully wiped away in a backward direction with sterilized absorbent 
cotton and the parts irrigated with lysol solution. 

The squatting position as practised among primitive peoples is often 




^^^^ 



Fig. 117. — Preserving the perineum. 

efficient in the second stage. It is the position naturally assumed when 
expulsive efforts are made with the abdominal muscles, and the pressure 
of the thighs against the abdomen tends to lift upward a pendulous uterus 
and bring its axis into coincidence with that of the remainder of the 
birth canal. Its disadvantages are the danger of precipitate expulsion and 
of perineal laceration. 



THE MANAGEMENT OF LABOR 



165 



Better, perhaps, is the exaggerated hthotomy position, popularized by 
DeLee. This retains the advantages of the squatting- position without its 
disadvantages. 

Care of the Perineum. — From a study of the causes of perineal lacera- 
tion it is easy to deduce the following principles of management : 

I. Descent and flexion of the fetal head should be complete before 
expulsion is permitted to occur. Thus only can the smallest diameter be 
made to present at the outlet. 



^x%^^^^«« -^-^^-^^T 






1 




^x 1 



Fig. ii8. — Another case. Preserving the perineum. 



2. The movements of extension, by which the final passage of the head 
is brought about, should be slow, gradual, and intermittent. 

3. The head should be delivered in the absence of a pain. 

4. Support of the perineum is not indicated. It is the head, not the 



166 PREGNANCY, LABOR AND THE PUERPERIUM 

perineum, that needs support and to which restraining pressure should be 
appHed. 

5. The posterior shoulder should not be allowed to plough through the 
perineum (Figs. 117, 118, 119 and 120). 

Tech NIC. — As soon as the head becomes visible during a pain, the 
attendant should be on his guard and ready to restrain its further advance 
if necessary. No active interference is indicated at this time, how^ever. 




Fig. 119. — The same case. Farther advanced. It is uLCorninti necessary to use the full hand in retard- 
ing the progress of the head. 



It is a mistake to begin treatment too early. He should be content to 
watch the gradual advance and recession of the head. Nature can do this 
part of the work better than art. When the head remains visible between 
the pains, constant vigilance is required, and as a larger and larger segment 
of the occiput appears, the physician should restrain and control its advance 



THE MANAGEMENT OF LABOR 



167 



by pressure applied to the head itself. Kneading and stretching the 
perineum, and passing the fingers between the occiput and the symphysis 
in search of imaginary obstacles, do no good, but only serve to increase the 
risk of infection. As the occiput is about to merge, it is grasped in the 
full hand and its too rapid delivery prevented. In easy cases it is sufficient 
to advise the patient to breathe with her mouth open and not to '' bear 




Fig. 120. — The same case again. Emergence of the forehead and face. No perineal tear visible as yet. 

down " during the final act of expulsion. If the patient is a primipara or if 
the suffering is severe, relaxation may be promoted, '' bearing down " 
efforts prevented, and pain abolished by the administration of an 
anaesthetic. 



168 PREGNANCY, LABOR AND THE PUERPERIU.AI 

Delivery of the Shoulders. — After the birth of the head there is usually 
a pause of variable duration before the shoulders are born. This gives the 
mother a short interval of rest, allows time for uterine retraction, and 
apparently does no harm to the child, whose face, however, becomes much 
congested. Few men know just how long this period would last, since few 
have the repose to wait long enough to see, and there would probably be no 
special advantage in doing so. If the cord is wound around the neck of 
the foetus it should be disengaged and drawn over the fetal head (Fig. 121), 
since the condition involves some danger of fetal asphyxiation. Most 

^^^^ writers advise, if the cord cannot 

r^^H be drawn over the head, it be cut 
^^M between two clamps, and the child 
^^M immediately extracted. This I 
^^H have never found it necessary to 
^^^r do. In case of delay in the extrac- 
tion of the shoulders, one would 
be in an awkward position. I 
must admit having torn the cord 
^^ in a few instances, but without 
^^> harm to the child. 

We now come to an important 
matter- — the delivery of the shoul- 
ders. It is my experience that 
most men have not mastered the 
technic of shoulder delivery. 
\ Clumsy work here may result in 

'^ \^ considerable delay, and it vastly 

^ increases the danger of perineal 
laceration, often transforming a 
>s very slight tear into one of the 
second or even third degree, and 
occasionally results in brachial 
paralysis. If the shoulders do not 

Fig. i2T.-Passing^aJoop^of the c^^^^ f^^^^^-^ ^J^^ ^^^^^ ^f^^j. ^ reason- 

able interval, patient should be 
quickly placed in the cross-bed position with her hips well over the edge 
of the bed, and, w^ith the two full hands placed on either side of the head 
and face, as shown in the accompanying illustration, traction made directly 
downward, i.e., toward the floor (Fig. 122). This downward traction 
cannot well be made with the patient lengthwise in bed. As soon as the 
anterior shoulder appears at the subpubic arch, the head is carried directly 
upward, i.e., toward the ceiling, and thus the posterior shoulder is lifted 
over the perineum, not allowed to plow through it. 

Physical and Moral Support. — When an athlete is about to undergo 
some test of courage, strength, oi endurance, or when a soldier is about to 






THE MANAGEMENT OF LABOR 



169 



undertake a long march, he is carefully trained. He is prepared for the 
ordeal by good food and plenty of sleep, and, while undergoing it, he is 
sustained, if necessary, by stimulants and oxygen, as well as by the support 






Fig. X22. — The same case as in Fig. 119, continued. Delivery of the anterior shoulder. Note the 

congestion of the child's face. 

and attentions of attendants and trainers. Napoleon it was who said, 
** An army marches upon its stomach." 

A woman who has before her a tedious or difficult labor needs the cour- 
age and endurance of soldier and athlete combined. And yet, how often 



170 PREGNANCY, LABOR AND THE PUERPERIUM 

do we find a patient about to begin the second stage of labor who has had 
neither sleep nor food for twenty- four hours ! This strange anomaly is 
not the result of lack of sympathy or solicitude on the part of those about 
her. It is due to the fact that people lose their heads at such a time. The 
patient herself naturally thinks little of food or sleep, her immediate rela- 
tives, more anxious than she, forget all about it, and the doctor, neglecting, 
perhaps, to mix common sense with his science, regards the problem as a 
purely surgical one. 

I have said above that a patient should be on her feet during the first 
stage. If, however, the first stage begins at night, or after a sleepless 
night, she should be encouraged to sleep between the pains, and, if the 
latter are unusually severe and the patient highly nervous and apprehensive, 
it is well to secure sleep by the administration of chloral, gr. xv, or a full 
dose of morphine hypodermically. 

The patient should receive a sufficient quantity of nourishing food early 
in labor, as it may be difficult to induce her to take it later. Milk and solid 
food in large quantities are perhaps not advisable, as anaesthesia may 
become necessary later. Soups, broths, weak tea, coffe, or wine if the 
patient is accustomed to its use, with a few crackers, are sufficient, and 
help to revive the patient's strength and improve her morale. 

If the patient's strength and courage begin to fail during the second 
stage, strong black coffee will often be found very helpful. If she 
prefers, a little wine or brandy may serve a similar purpose. 

Skilled nurses and sympathetic attendants can do many little things 
that are grateful to the patient. Pressure over the sacrum during the first 
stage usually gives some relief, and as the pains become more severe the 
patient finds the presence and the physical support of some friend or 
nurse a great help. Oversolicitous relatives, however, usually do more 
harm than good. ^Moistening the mouth and lips, which often become dry 
during the expulsive efforts of the second stage, rubbing the legs for the 
painful cramps that so often occur at this time, are examples of little things 
that in the aggregate mean a great deal. And to physical aids should be 
added sympathy and encouragement and kindly direction. 

Starvation, loss of sleep, and mental depression, constitute a poor 
preparation for the tremendous ordeal of the second stage of labor. 
Going back to the original Greek, we find that the word obstetrician means 
one who " stands by " his patient. He is a poor doctor and she a poor 
nurse who Is so absorbed in scientific or technical study as to forget this 
meaning. 

Attention to the Foetus. — The attendant should never forget that he 
has two patients Instead of one, and that he is responsible for the patient 
whom he cannot see as well as for the patient whom he can see. There- 
fore he should auscultate the fetal heart at intervals during the entire 
course of labor. In operative cases, in premature rupture of the mem- 
branes, or whenever any complication is present, he should be especially 



THE MANAGEMENT OF LABOR 171 

careful. The mother is always grateful for any evidence of interest in 
the child, and there is no doubt that now and then the timely recognition of 
impending asphyxia may result in the saving of fetal life. This is espe- 
cially true of delayed second stage. Should the attendant have reason to 
fear for the welfare of the child, it is not wase to tell the mother, but for his 
own protection he should inform some member of the family. 

The general subject of the auscultation of the fetal heart has already 
been dealt with, but it may be well again to remind the reader that in the 
second stage of labor, when the recognition of the fetal heart sounds is 
most important, they are best heard in the median line, an inch or two 
above the symphysis. It has been my observation that many men forget 
the self-evident fact that with the descent and forward rotation of the 
foetus there is a corresponding change in the location of the maximum 
intensity of the fetal heart sounds. 

It is of the utmost importance that the physician should, early in his 
career, become accustomed to the auscultation of the fetal heart, both with 
and without the stethoscope. But no man whose sense of hearing is 
iinimpaired is too old to learn. 

This auscultation of the fetal heart is of special importance in delayed 
second stage when the head is well down in the pelvic cavity and inter- 
ference is easy and attended with little danger to the mother. The mere 
fact that one cannot hear the fetal heart is of less significance than a 
slowing or irregularity in sounds that have previously been normal. This 
subject will be further considered in the chapter on fetal" asphyxia. 

The care of the child's eyes and the first dressing of the umbilical cord 
should be regarded as important parts of the management of labor, to be 
entrusted to the physician, or at all events to be performed under his direct 
supervision. 

Ligation and Care of the Cord. — As soon as the head is born, the 
attendant should determine by touch whether the cord is wound about 
the neck of the child, and, if it is, a loop or more, if present, should be 
drawn over the head. Some writers advise that if this cannot be done, the 
cord should be ligated and severed and the child rapidly delivered. I have 
never felt obliged to do this, though I must admit having torn the cord two 
or three times, fortunately without harm. If one should ligate the cord 
and then find difficulty in extracting the child, the position would be an 
awkward one. 

The cord should not be ligated until pulsation has ceased. If it is 
ligated at once the child loses some of the reserve blood of the placenta 
which it would otherwise receive. After the pulsation has ceased or has 
become very faint, the cord is ligated about an inch and one-half from the 
abdominal surface. It is always wise to leave the stump long enough for 
a second ligature should this prove necessary. Only what is sterile should 
be allowed to approach. The stump should then be well covered with 
sterile gauze or cotton and thus protected until the cord is dressed. 



172 PREGNANCY, LABOR AND THE PUERPERIUM 

The first dressing of the cord is a very important matter. If there is 
a well-trained nurse in attendance it may be entrusted to her, but other- 
wise it should be performed by the physician himself. Under no circum- 
stances should this task be entrusted to an ignorant bystander or an 
untrained nurse. Serious and even fatal consequences may follow. 

Various complicated methods have been devised. No one of them is 
essential. Simple asepsis is all that is necessary. The hands that handle 
the cord should be gloved and the scissors with which it is cut and the tape 
with which it is tied should be sterile. The use of irritating chemical solu- 
tions probably does more harm than good. After it has been ligated it 
should be wrapped in sterile absorbent cotton, which tends to absorb any 
moisture and to promote prompt desiccation and separation, and wrapped 
in sterile gauze. The whole should be kept in place by a band about the 
abdomen which should be so arranged as to keep the cord dressings securely 
in place without interfering with respiration. On no account should the 
child be given a tub bath at this time. This practice, so common among 
nursery wiseacres, is a fruitful source of infection. Such a bath should be 
deferred until after the cord has separated. 

Prophylaxis of Gonorrhoea! Ophthalmia. — i\nother duty of the at- 
tendant at this time, and one which should on no account be neglected, is 
the prophylactic instillation of silver solution into the eyes of the child. 
Bitter regret has more than once been the portion of the man who sup- 
posed that he knew the history of both parents too well to be deceived. It 
should not be forgotten that many an innocent woman is the unconscious 
victim of gonorrhcea. 

The formula is easy to remember. One drop of a one per cent, solu- 
tion in each eye. Neutralization with salt solution is superfluous. The 
one per cent, solution seems to be effective without producing the rather 
severe reaction that sometimes follows the use of the two per cent, solution 
originally proposed and used by Crede. Argyrol in 25 per cent, solution 
is less irritating and is said to be equally effective. 

Management of the Third Stage 
With the delivery of the child begins the third stage of labor. I am 
accustomed to consider its management under three heads : 

1. The prevention of infection. 

2. The prevention of hemorrhage. 

3. The supervision of the expulsion of the placenta and membranes. 

As to the prevention of infection, the principles and methods of disin- 
fection are, of course, the same as at previous periods of labor, but the 
necessity for noninterference is obviously much greater. While unneces- 
sary examinations and manipulations are objectionable before delivery, 
they are doubly so afterward, when a multitude of small lacerations and 
abrasions, which soon heal if left alone, offer as many avenues for the 
introduction of sepsis. 



THE :MANAGEMENT of labor 173 

Some obstetricians advise that the cervix be inspected and, if necessary, 
repaired immediately after dehvery. This is, of course, imperative if the 
tear is large enough to cause hemorrhage, and it is perhaps wise after 
versions and high or mid-forceps operations if the surroundings are 
favorable and the patient's condition warrants it ; but its routine adoption 
in normal labor would, in my opinion, do more harm than good. Bad 
tears of the cervix are not common in normal labor, and moderate tears 
often sink into insignificance during involution. 

Perineal lacerations that endanger the integrity of the pelvic floor, of 
course, require immediate repair, and the same statement applies to the 
larger superficial lacerations of the perineum. These, however, occur 
chiefly in primiparse, and little internal manipulation is necessary to 
determine their presence. To distend the cervicovaginal canal in search 
of small tears whose edges are in apposition and have no tendency to 
separate, would be ludicrous, if it were not so dangerous. 

The traditional postpartum douche is happily a thing of the past. Here 
again the efi:'orts of nature are superior to those of art. Not only are the 
vaginal secretions antagonistic to the germs of infection, as Doderlein and 
others have shown, but after delivery the entire birth canal is flooded with 
blood and liquor amnii, which some one has not inaptly called a normal 
salt solution, and the foetus and placenta, both aseptic, are during their 
emergence, at all times, closely embraced by the contracting ostium 
vaginae, so that neither air nor foreign body can enter. Here there is 
clearly no reason for a postpartum douche unless some enterprising person 
has given an antepartum douche. Clinical experience confirms this view. 

The practice of inserting the fingers into the vagina in search of 
placenta or membranes is, as we shall presently see, a bad one, and is 
seldom necessary in the hands of the man who has learned how to manage 
the third stage of labor. In ordinary cases the genital canal should be let 
alone after delivery unless laceration or hemorrhage make interference 
necessary. In such cases rubber gloves should always be worn. 

After the expulsion of the placenta and membranes, the parts are irri- 
gated from above downward with lysol or bichloride solution and covered 
with a large pad of sterile absorbent cotton which is held in place by a 
dry dressing fastened to the binder in front and behind. After all first 
labors, operative deliveries, and perineorrhaphies it is my custom to have 
this cotton pad wrung out of a weak antiseptic solution (one per cent, 
lysol) and applied moist to the vulva. After much bruising or laceration 
of the parts, nothing is more grateful to the patient than a hot moist 
compress. This compress also serves to promote drainage, and probably 
to exclude infection, and may be continued for the first two or three davs. 

If there is no trained nurse at hand, it is the hoiinden duty of tlic physi- 
cian to make the first vulvar dressing himself. This takes no extra time, 
since he should not leave his patient for an hour in any event, and in so 
doing he assures himself that, during the first few hours after deliverv. the 



174 PREGNANCY, LABOR AND THE PUERPERIUM 

time when infection is most likely to occur, and when if it does occur it is 
most likely to be of the severe type, his patient is protected. There is no 
doubt that many infections have their origin at this time. To maintain 
careful asepsis during the first and second stages of labor, and turn the 
patient over at the most critical period to the attentions of her family and 
friends, is a reversal of the ordinary processes of logic. 

The nurse should be instructed not to remove this first dressing until 
the patient is obliged to urinate, after which a new dressing should be 
applied. She is also carefully instructed in the manner of making the 
subsequent dressings, as described in the next chapter. 

We endeavor, then, to prevent infection during the third stage by 
scrupulous cleanliness, avoidance of all internal manipulations that are not 
clearly indicated and by particular attention to the first vulvar dressing. 

The prevention of hemorrhage and the supervision of placental expul- 
sion are considered together. During the delivery of the foetus the fundus 
should be followed down by the hand of the accoucheur and the behavior 
of the uterus carefully noted. If all is well it will be felt as a hard ball, 
above the symphysis, but well below the umbilicus. If it is so felt, and if 
there is no hemorrhage from the vagina, further manipulation is better 
omitted, but the hand should be kept in position and the uterus carefully 
watched. If there is a tendency to relaxation, the uterus should be 
massaged by a rotary movement, made with the tips of the fingers applied 
over the fundus, until it becomes hard again. 

It is a great mistake, however, needlessly to irritate an already con- 
tracted uterus by constantly rubbing and massaging it, and making pre- 
mature and repeated efforts at expulsion of the placenta. In this way 
there is often produced a tetanic contraction of the uterus, as harmful, 
while it lasts, as that produced by ergot and often causing retention of the 
placenta. This is a very common mistake of the young practitioner. The 
term '' holding the fundus " should be expunged from our hospital* 
vocabulary, and the term " watching the fundus " substituted. The fundus 
should be watched, however, for at least an hour after the expulsion of 
the placenta, or, better, two hours. Of course this is usually unnecessary, 
but it should never be omitted. Sudden relaxation and severe hemor- 
rhage may occur most unexpectedly, even after a perfectly normal labor. 

Too often both doctor and nurse seem to think that with the birth of 
the child the necessity for watchfulness is over. This is a great mistake. 
In the average case the two hours following delivery constitute, as far as 
treatment is concerned, by far the most important part of the whole 
parturient process. 

In some cases the placenta follows the child immediately, but this is 
the exception. As a rule, it is from five or ten minutes to a half-hour 
before the placenta is either wholly or partly in the vagina, and this is 
indicated by the fact that the fundus rises above the umbilicus without, 
however, becoming relaxed or soft. This sign, emphasized by Whitridge 



THE MANAGEMENT OF LABOR 



175 



Williams, I have found of much practical value. When the fundus has 
risen in this manner, it is usually easy to express the placenta by simply 
pressing the uterus downward and forward in the axis of the brim (Figs. 
123 and 124). 

As long as the uterus remains firmly contracted below the umbilicus 
the placenta is probably still undetached, but I have occasionally noted 
exceptions to this rule. 

If, however, moderate pressure does not avail, or if the uterus remains 
firmly contracted above the symphysis and does not change its position, 
it is better to wait from half an hour to an hour before attempting to 
express the placenta. On the whole, there is a general tendency to 




Fig. 123. — Expulsion of placenta aided by pressure over fundus after complete separation. 

hasten unduly the termination of the third stage of labor. Not only do 
premature efforts in this direction cause tetanic spasm of the uterus, as 
already mentioned, but, even if successful, they disturb the normal 
mechanism of placental expulsion, prevent the formation of the retro- 
placental hsematoma, and thus, by a strange irony of fate, hemorrhage, 
placental retention, and infection are caused by the very means employed 
to prevent them. But the uterus must be watched meanwhile. 

We cannot, however, wait indefinitely for the expulsion of the placenta. 
If no progress has been made in from half an hour to an hour it should be 
expressed by the Dublin method, generally known as the method of Crede, 
which is well illustrated in Fig. 125. The operator waits for a contraction, 
or, if one is not forthcoming he produces one by light massage of the fun- 
dus. As the contraction reaches its height the four fingers behind the uterus 



176 



PREGNA^XY, LABOR AND THE PUERPERIUM 



and the thumb in front make pressure directly downward, i.e., tov/ard the 
floor, while the placenta is at the same time squeezed from the uterus as a 
cherry-pit is squeezed from a cherry. Sometimes the uterus is so large 
that it can hardly be grasped in one hand. In this case two hands may be 
used, eight fingers behind and two thumbs in front. Crede's method re- 
quires a little practice, but once learned, it will be found of great value. 

Two very common mistakes must be avoided. Be sure that the uterus 
is contracting before you undertake expression. JMake pressure directly 
downward in the axis of the pelvic brim. The beginner almost invariably 
makes pressure forward, compressing the uterus against the symphysis. 
This hurts the patient and does no good whatever. 




Fig. 124. — Placenta and membranes fall into the hand. 

Crede's method is not to be used in every case, but only in case of 
hemorrhage, or when the usual methods have failed and from half an 
hour to an hour has elapsed since the birth of the child. It is a measn^re 
of necessity, not of choice. It is sometimes quite painful, and repeated 
efforts may induce considerable shock. Used too early it disturbs the 
normal mechanism of labor and tends to cause, rather than to prevent, 
hemorrhage. But properly employed it has great advantages. In case 
of hemorrhage or obstinate placental retention, it enables the operator 
to empty the uterus without introducing the hand, thus greatly lessening 
the danger of infection. 

It is an invaluable expedient, to be reserved for certain cases of emer- 
gency. To practise it as a matter of routine or convenience in every case 
is a dangerous blunder. 



THE MAXAGEMEXT OF LABOR 



177 



Adherent placenta, i.e., attachment of the placenta to the uterine wall, 
is very rare, and, when it does occur, is usually a concomitant of syphilis. 
In cases of true adherent placenta, it may be necessary to introduce the 




Fig. 125. — Expressing the placenta by the method of Crede. 

hand into the uterus and separate the placenta from the uterine wall. 
Manual removal of the placenta may also be indicated in cases of hemor- 
rhage if the placenta is still in utero and Crede 's method is not promptly 
successful. But it may be taken for granted that the man who reports 



178 PREGXA.XCY, LABOR AND THE PUERPERIUM 

many cases of adherent placenta, or who often finds it necessary to 
introduce his hand into the uterus, has yet to learn the management of the 
third stage of labor. 

When the placenta has passed the orifice of the vulva, it is revolved 
a few times in the hands, in order that the membranes mav be twisted 




Fig. 126. Twisting the membrane into the form of a rope to prevent tearing. 

into the form of a rope and thus be less likely to tear (Eig. 126). This 
procedure has been criticised of late, but after a large experience I am 
convinced that it is very useful. The placenta is twisted rather than 
pulled, little or no traction being made (Fig. 127). 

The placenta and membranes should always be carefully inspected 
to make sure that nothing has been left behind. After looking over the 



THE ^lAXAGE^IEXT OF LABOR 



179 



maternal surface the placental border should be inspected. Torn vessels 
indicate the existence of a placenta succentnriata. If the beginner would 
see how a placenta looks when one or more cotyledons are missing, let 
him remove them from a normal placenta and then study the mutilated 




Fig. 127. — Inspecting the placenta. 

organ. Masses of retained placenta, of course, require removal. If 
attached to the uterine wall they prevent involution, keep the sinuses 
open, thus favoring infection, and sometimes causing profuse hemorrhage 
hours or even days after delivery. 



180 PREGNANCY, LABOR AND THE PUERPERIUM 

The retention of pieces of membrane or even the whole chorion is of 
no great importance. At all events, it is a lesser evil than the introduction 
of the hand into the uterus for their removal. Such fragments usually- 
come away in a few days without causing any great trouble. 

If there has been a slight or moderate tear of the perineum, the 
physician may, while waiting for the delivery of the placenta, employ 
his time in placing the sutures, taking advantage of the fact that the 
patient is still perhaps under the influence of the anaesthetic, but they 
should not be tied until the placenta has been expressed. Only tears of 
the first degree can be properly repaired at this time. . . . 

The Preservation of the Perineum. — This is one of the most important 
duties of the accoucheur. Neglect or ignorance in this particular may 
condemn a patient to a life of chronic invalidism. Why and how this 
happens are questions that are answered in text-books on gynaecology and 
need not concern us here, but the fact remains not to be forgotten. 

Frequency. — Statistics on this point are very misleading. Perineal 
tears vary in frequency according to the skill of the obstetrician. In a 
general way, however, we may say that under average management tears 
involving more or less of the perineal body occur in about twenty-five 
per cent, of primiparae and in about five per cent, of multiparae, while tears 
of the fourchette are found in the great majority of cases. 

Varieties. — Excluding mere '' nicks," or tears of the fourchette only, 
perineal tears are conveniently divided into those of the first, second, and 
third degrees. 

First degree tears involve the fourchette and more or less of the 
perineal skin and vaginal mucous membrane. 

Second degree tears are those in which more or less of the perineal 
body is involved but which do not include the sphincter ani. These tears 
usually extend up one or the other vaginal sulcus, dividing the levator ani 
to a greater or less extent. 

Third degree tears are those which divide the sphincter, and, usually, 
more or less of the rectovaginal septum. 

Causes of Perineal Laceration. — What are the causes of perineal 
laceration? We must be able to answer this question before we can 
formulate any intelligent scheme of prevention. 

The most common cause is rapid and sudden expulsion of the head. 
It is a matter of common observation that when the head is suddenly 
expelled at the height of a contraction a tear usually results. Next in 
frequency perhaps is unusual disproportion between the head and the soft 
parts of the mother. In certain women who are often, but by no means 
always, elderly primiparae, the tissues are so friable that they will tear, no 
matter how skilfully the case is conducted. 

As a rule the worst tears occur in operative cases, especially in unskil- 
fully conducted forceps operations. 

In breech extractions, if there is much disproportion in size between 



THE MANAGEMENT OF LABOR 181 

the foetus and the maternal parts, lacerations are common and sometimes 
quite unavoidable. 

\\'hen the symphysis is long and the pubic arch narrow, the head may 
be directed so far backward that rupture is inevitable, and the same thing 
may happen in cases of outlet contraction, or of abnormal pelvic inclination. 
As might be expected, laceration is more frequent in malpositions and 
malpresentations. Instances will at once occur to the reader. Perhaps 
the most common is posterior position of the occiput. A small part pro- 
lapsed alongside of the head obviously increases the danger. Not very 
infrequently one encounters a hand in this position. 

Finally, faulty technic in the delivery of the shoulders is not to be 
forgotten. 

Since tears occur five times as often in primiparae, it is evident that 
primiparity is a predisposing cause. 

Care of the Perineum. — The reader will note at once that some of 
these causes are preventable, e.g., we can and should control the progress 
of the head, and we can and should learn to perform our forceps opera- 
tions with deliberation and skill. On the other hand, we cannot help the 
friability of the tissues or the shape of the pubic arch. It follows, of 
course, that the attendant is not responsible for all tears of the perineum. 
In many cases no blame whatever can be attached to him. He can be 
blamed, however, and probably will be blamed if he makes no attempt 
to repair the laceration. This should never be forgotten. Nor should he 
forget that, if for any good reason he does not feel like undertaking an 
immediate repair, the operation can be performed just as well, or perhaps 
better, the next day. Indeed, there are certain undeniable advantages in 
performing the operation from twelve to thirty-six hours after delivery. 

j\Iany a patient has been denied the advantage of perineal repair 
because her physician very properly hesitated to risk additional shock 
after a severe operation or a profuse hemorrhage, but did not appreciate 
the opportunity of operating a day or two after labor. All this, however, 
will be considered in connection with the repair of perineal lacerations. 

The physician should remain with his patient for at least an hour after 
the delivery of the placenta. In cases of uterine relaxation, in cardiac 
cases, after severe operations, or prolonged anaesthesia, and in all doubtful 
or critical cases, the time should be extended to at least two hours. Before 
taking his leave he should satisfy himself that his patient is clean and 
comfortable and that hemorrhage is not going on. In all doubtful cases 
at least this latter point should be settled by actual inspection since, as 
we shall see later, severe bleeding may occur when the fundus is well 
contracted, e.g., after laceration of the cervix or placenta praevia. If the 
patient is in a hospital it is wise to leave express and emphatic orders 
that the patient be not catheterized except by direction of the attending 
physician. Unnecessary catheterization done as a matter of routine has 
often led to deplorable results. But of this more in a subsequent chapter. 



CHAPTER IX 

THE PHYSIOLOGY AND CLINICAL HISTORY OF THE 

PUERPERIUM 

The puerperium, or lying-in period, comprises the period extending 
from the end of labor mitil the organs and tissues concerned in the child- 
bearing process have returned to their normal condition. To be sure, 
their condition after labor is never exactly the same as before, but this we 
-have already considered. Strictly speaking, this would mean from six 
weeks to two months. According to general custom, however, the patient 
remains under the care of her physician about as long as she remains in 
bed, i.e., from ten days to three or four weeks. Of course, this custom 
is not a good one. In cases that are in all respects normal it may answer 
well enough, but no one can be sure of such cases in advance. It is far 
better that the patient be under the observation of her physician for a 
month after delivery. But, before we come to the management of this 
period, we must consider the phenomena which normally accompany it. 
These phenomena are not only of great practical importance, but are highly 
interesting as well. 

Involution of the Uterus. — At the close of labor the uterus, which still 
occupies a large part of the abdominal cavity and weighs a thousand 
grammes or more, must be reduced to something like its original size and 
weight, and be hidden again within the pelvic cavity. How is this 
accomplished ? 

It was formerly supposed that the entire uterine muscle is dissolved 
and cast off, the patient being provided as it were with a new uterus after 
each labor. It remained for Robin and Sanger to point out the fallacy 
of this conclusion, and to show that the primitive fibres remain to form 
perhaps the starting points for another hypertrophic process in a future 
pregnancy. It is for the most part only the unnecessar}^ protoplasm that 
is removed. 

The process is principally one of fatty degeneration, and is caused 
by the constriction of the blood-vessels which supply the uterine muscle, 
•and the consequent cutting off of its blood supply. The contractions of 
the uterus, which continue after delivery as well as before, have other 
objects than the prevention of hemorrhage. Of course the uterine con- 
nective tissue is also involved but its amount is relatively so small that this 
is of minor importance. 

During the latter part of pregnancy, the way is prepared for the final 

separation of the placenta and membranes, by fatty degeneration in the 

jrlandular layer of the vera and reflexa. After the completion of the 

third stage of labor nothing is left but the deepest portion of the decidua 

i8:a 



THE PHYSIOLOGY OF THE PUERPERIUM 



183 



containing connective and glandular tissue. There is an active leucocytosis 
with the formation of a granulation layer, necrosis and casting off with 
the lochia of the outer cellular layer, and preservation of the deeper 
glandular layer, from which the regenerated endometrium is to be formed. 
This formation is brought about by proliferation of gland and connective- 
tissue cells and aided by the constant diminution in the size of the uterus 
and therefore of the area to be reconstructed. 

AVounds of the cervix, vagina and perineum heal, or fail to heal, much 
as do wounds of mucous membrane under other circumstances, and the 
process requires no special description. In its gross features it is familiar 




Fig. 128. — Frozen section just after completion of third stage of labor, showing collapse of lower 
uterine segment and cervix. C R., contraction ring; O. E., external os; O. /., internal os. (After 
Benckiser.) 



to all who have taken the trouble to watch their postpartum cases with care. 
Characteristics of the Postpartum Uterus. — There are two 
characteristic features of the postpartum uterus which should be con- 
stantly kept in mind if one would understand the phenomena of the puer- 
perium — its extreme mobility, and its marked anteflexion. The thin, 
relaxed, lower uterine segment offers no resistance to movement in any 
direction, and the normal anteflexion of the uterus is much more marked 
at this time and increases from day to day. The large and heavy fundus 
falls forward, making a pronounced angle with the cervix. Indeed, so 
sharp is this angle in some cases, that the lochial discharge is arrested. In 
cases with a tendency to retroversion the fundus may fall backward. This 



184 



PREGXAXCY, LABOR AXD THE PUERPERILAI 



condition called by the Germans locJiioiuctra will engage our attention 
later. There is a tendency for posterior displacements to be exaggerated. 
Prolapse of the uterus too often dates from this time. 

The great mobility of the puerperal uterus is strikingly shown by the 




■/■'-.h 



V 



24 HQURS 

Fig. 129. — Position of fundus of uterus twenty-four hours after labor. 



changes of position which it undergoes with the alternate filling and empty- 
ing of the bladder. There is a somewhat similar, though less striking, 
change attendant upon the distention of the rectum. According to Fabre 
the fundus ascends one centimetre for every on 



hundred grammes of 



THE PHYSIOLOGY OF THE PUERPERIUM 



185 



urine in the bladder, while a full rectum causes it to ascend three centi- 
metres. From this it is sufficiently evident that we cannot draw conclusions 
from the height of the fundus unless we know the condition of the bladder 
and rectimi, especially the former. 



^--^ 



r 




VA 



48 H 



^URS 



Fig. 130. — Position of fundus of uterus forty-eight hours after labor. 

Immediately after the completion of the third stage of labor the uterus 
should be found well contracted and below the level of the umbilicus. If 
the physician examines the patient the next morning the fundus will be 
found in the region of the liver (Figs. 128 and 129). Sometimes, much 



186 PREGNANCY, LABOR AND THE PUERPERIUM 

less often, the fundus will be found at the same height but upon the left 
side in the neighborhood of the spleen. It is only in rare instances that it 
is found in the median line. This change of position is due to the disten- 
tion of the bladder which is uniformly present at this time. On the 
second day the fundus is at a lower level owing to the fact that the bladder 
has been emptied (Figs. 130 and 131). On the following day the fact 
that the rectum has been emptied has aided in the continued descent of the 
fundus (Fig. 132). 

^Moreover, there is another fact that it is necessary to bear in mind. 
The puerperal uterus is no longer a cavity. The cavity has been emptied 
and the walls are in contact. At least this is the normal condition. The 




Fig. 131. — Sagittal section of the pelvic organs of a puerpera on the second day after delivery. (Ahlfeld.) 

lax uterus of a multipara does not contract as well as does that of a 
primipara. Hence the greater frequency of " after pains," which are 
really nothing more nor less than the efforts of a lax uterus to expel a 
blood clot. 

The interior of the uterus is smooth except at the placental site where 
there is a distinct roughness due to the presence of thrombi in the vessels. 
The student and practitioner is usually left to find this out for himself, 
to assume in other words that the uterine interior is uniformly smooth, a 
serious error on the part of his teachers. The result of an effort to 
remove it with the curette (and such efforts have been occasionally made) 
may be better imagined than described. 



:.! 



THE PHYSIOLOGY OF THE PUERPERIUM 



187 



Involution of Cervix and Vagina. — Immediately after delivery the 
cervix is hardly recognizable as a cervix. At least, this is true of all 
primiparous labors and of all difficult and operative cases. Apparently 
this fact is not generally known. It is keenly appreciated, however, by 




'>r^%4 



3 DAYS 



Fig. 132. — Position of fundus of uterus three days after labor. 

those who have been called to sew up a cervical tear in order to stop 
hemorrhage. 

Despite all this, the cervix soon shows signs of progressive return to 
the normal. The internal os is first to reg^ain somethino- like its natural 



188 



PREGNANCY, LABOR AND THE PUERPERIUM 



form and dimensions. It contracts with remarkable rapidity and at the 
end of three days hardly admits two fingers. By the third week the cervix 
is closed, not even admitting the finger. All this, of course, only if con- 
ditions are normal. In cases of subinvolution or infection, and especially 
of retained secundines, the cervix often admits the finger even during the 
third or fourth week. 

Immediately after delivery the ostium vaginae is completely relaxed 



Internal os-^ 



Thrombus at 
the placental 
site 



External os 




Fig. 133. — Puerperal uterus of the fifth day. After a frozen section of the Basel clinic. Internal os 
closed, external os and cervical canal still gaping. 



and ofifers no resistance to the introduction of the fingers. There is no 
suggestion of a sphincter. In a day or two, however, contraction begins, 
and from this time on the vagina gains rapidly in tone and contractile 
power. A certain friability of the tissues, however, persists for some 
weeks. They tear rather than stretch, and are more vascular than usual. 
This fact has been noted and emphasized by DeLee, and is well worth 
remembering. He quotes reports of many cases of injury with severe 



THE PHYSIOLOGY OF THE PUERPERIUM 



189 



"bleeding occurring during too early coitus. Bleeding was always a 
prominent symptom. 

The Descent of the Fundus. — The descent of the uterus continues for 
ten or twelve days at the rate of about one centimetre per day until it can 
no longer be felt above the symphysis. This period is not uniform, how- 
ever. In easy cases the period may be a day or two shorter, whereas in 



Internal os 



External os 




I Placental 

site 



Fig. 134. — Puerperal uterus of the twelfth day. 

difficult cases or in cases of sepsis or subinvolution it may be very much 
longer (Figs. 133 and 134). 



Clinical Course of the Puerperium 

The Postpartum Chill. — The third stage of labor is often followed by 
a well-marked chill, which is a common source of alarm to the inexperi- 
enced; but is of no clinical significance. It is probably of vasomotor 
origin, and due to the recession of a large quantity of blood from the 



190 PREGNANCY, LABOR AND THE PUERPERIUM 

superficial vessels, though the loss of blood and the inevitable exposure 
following the exertions of the second stage doubtless contribute their 
part. I have been struck by the fact that it is much more common in 
the case of patients delivered at home than in the warm air and equable 
temperature of the hospital delivery room. 

The Temperature. — As a rule the temperature should not be higher 
during the lying-in period than at other times. There are occasional 
exceptions, however. After long and difficult labors, and especially after 
operative deliveries, the temperature may rise to ioo°, or thereabouts, 
without any special acceleration of the pulse or other special symptoms, 
only to fall again within the next twelve hours. 

After difficult obstetric operations the temperature may rise immedi- 
ately to ioi^° or 102° and remain at that point for two or three days. 
This is variously attributed to shock, mild infection, or some unknown 
influences. There is usually a corresponding acceleration of the pulse, 
together with some evidences of shock. 

The subject of septic and nonseptic causes of fever is discussed in the 
chapter on puerperal infection. 

The Pulse. — The slow pulse of the puerperium is proverbial. It is 
usually between sixty and seventy, though in some cases it becomes even 
slower, perhaps forty or fifty. I believe there is no doubt of the existence 
of this phenomenon, though one observer came to the curious conclusion 
that the pulse is actually more rapid during the puerperium than before. 

Various reasons have been adduced for the slow pulse of the puer- 
perium. To me the fact that the work to which the heart has gradually 
become accustomed is suddenly and markedly reduced by the discon- 
tinuance of the utero placental circulation, is altogether the most plausible. 
Additional factors, no doubt, are rest in bed and a restricted diet which, 
during the lying-in period, as at other times, tend to reduce the rapidity 
of the heart's action. 

The Bladder.-^Sluggish action of the bladder is common during the 
puerperium, and the condition is still further aggravated by the fact that 
the urinary secretion at this time is greater than usual. The chief factors 
in causing retention are the recumbent position and the bruising and swell- 
ing of the urethra and adjacent structures. Contributing factors are 
spasm of the urethra, nervousness, lowered intra-abdominal pressure, and 
weakness and relaxation of the abdominal muscles. The very important 
subject of the treatment of this condition will be discussed in the next 
chapter. 

The Bowels. — Constipation for the first few days is the rule. The 
recumbent position, paralysis of the intestinal muscles from pressure, and 
weakness of the abdominal muscles from the exertions of labor, are among 
the causes. Probably the recumbent position and the traditional milk 
toast and tea are chiefly at fault. 

The Skin. — Elimination by the skin is active at this time. The 



THE PHYSIOLOGY OF THE PUERPERIUM 191 

patient perspires freely at night, and perhaps complains of the " night- 
sweats," to which she is subject. The surface of the body is cool and 
moist. Frequent bathing is appreciated. A dry skin is not of good omen 
at this time. It may mean fever or toxaemia. 

The Nervous System. — The nervous system is more or less affected, 
especially in sensitive and impressionable women. Emotional crises are 
easily brought about. DeLee says that puerperae hear more acutely, 
and are unusually sensitive to lights and odors. They are certainly very 
sensitive to petty annoyances and to real or fancied slights. All this is 
accentuated by the patient's feelings of helplessness. Transient rapidity 
of the pulse and irregular elevations of temperature are easily excited. 
On the other hand, there are many women of phlegmatic temperament 
who regard the whole matter with equanimity. 

Appetite. — The appetite is said to be diminished. I do not think 
that this is true except as far as circumstances, e.g., confinement to the 
house and bed, make it so. In my experience it has been quite common 
for the patient to ask for something to eat shortly after delivery. 

Thirst is marked both before and after delivery. Before delivery it 
is caused by the exertion of the second stage and the parched and dry 
condition of the mouth and throat that accompanies it and that soon 
becomes familiar to every observer. After delivery, and during the 
days that follow, it is the result of the hemorrhage that occurs at the close 
of labor and of the free elimination and excretion that follow. 

Weight. — When the starvation diet was in vogue the patients lost 
considerable weight during the puerperium. Gasser found an average loss 
of 4500 grammes during the first week. Others estimated it as one-tenth 
of the total body weight. In these days of more liberal diet the amount 
is much less, though when the patient first leaves her bed the loss of flesh 
is usually perceptible. Many patients gain in weight after the first "few 
weeks have passed. 

The Lochia. — This is the technical name for the vaginal discharge 
which continues for some weeks after delivery and which serves the 
purpose of ridding the uterus of the deeper decidual layer and of various 
other debris which must be gotten rid of in the process of involution. The 
classification of the older writers is still convenient and useful. For the 
first three days the discharge is largely mixed with blood, the lochia rubra. 
During the next few days there is a large admixture of serum, the lochia 
serosa. x\fter this, owing to the presence of leucocytes in large numbers, 
the discharge becomes whitish, the lochia alba. It disappears as a rule 
in two or three weeks. In easy cases it may disappear earlier ; while in 
more difficult cases, e.g., in primiparae, or after operative or complicated 
deliveries, its duration is greater. 

If the patient leaves her bed and resumes her household duties early, 
perhaps about the tenth day, the discharge becomes red again from the 



192 PREGXAXCY, LABOR AND THE PUERPERIUAI 

admixture of blood due to the reopening- of small wounds that have not 
quite healed, the lochia cruenta of the older writers. 

The cessation of the lochial discharge marks the regeneration of the 
uterine mucous membrane and is of course a favorable prognostic. Its 
long continuance is of less favorable import, denoting perhaps infection or 
subinvolution. It may be caused by retention of some part of the secun- 
dines. This is very common after abortions. 

Whether the normal uterine lochia contain virulent pyogenic organisms 
and may thus become the source of infection has been much debated. 
Personally I believe that Kronig and Williams are right in maintaining 
that this is not the case. At all events this seems to be indicated by the 
fact that with proper precautions infection is of the rarest occurrence. 
All observers agree, however, that pathogenic organisms inhabit the lower 
part of the vagina and are found in abundance about the vulva. But more 
of this subject when we come to discuss the subject of puerperal infection. 
A bad odor with the lochia may be an indication of saprsemia, or, more 
rarely, of a severe type of infection ; or, it may be simply the result of lack 
of external cleanliness. 

The lochial fluid is alkaline in reaction. During the first few days 
its characteristics are largely those of the blood with which it is so freely 
admixed. Microscopic examination shows the presence of red corpuscles, 
leucocytes, and epithelial and decidual debris. Later the discharge con- 
sists largely of serum from the mucous membrane as in the healing of 
mucous surfaces in other parts of the body. The white color of the lochia 
alba is due to the plentiful admixture of leucocytes. ]\Iuch printer's ink 
has been wasted in the effort to describe the odor of the lochia, but this 
can only be learned by experience. 

Tympanites. — A moderate degree of tympanites is an accompaniment 
of the puerperium. It is more noticeable after long and difficult labors and 
operative deliveries. It is probably due partly to paresis of the bowel 
from pressure and partly to constipation and the accompanying fermen- 
tation. It is more noticeable after difficult operative deliveries, and is 
common after the Caesarean section, especially when the operation is per- 
formed late in labor. In pronounced cases the distention is so great as to 
cause anxiety, but if peritonitis or other serious complication is absent 
the patients usually recover. 

The Blood. — ^On the whole there is little change in the blood at this 
time. Alost common is a moderate anaemia with the usual diminution 
in the amount of red corpuscles and of haemoglobin. The patient looks as 
though she had had a moderate hemorrhage, as is indeed the truth. There 
is one fact, however, which should never be forgotten. During labor and 
for a few days thereafter a marked leucocytosis can be demonstrated. 
This fact which we owe to Hofbauer, and of which many are apparently 
ignorant, is of importance from the standpoint of diagnosis. It is often 
adduced as an evidence of infection when in reality it is nothing of the 



THE PHYSIOLOGY OF THE PUERPERIUAI 193 

sort, and incidentally it may in this way lead to undeserved censure of the 
medical attendant. 

The Urine. — We have already noted that the quantity of urine is 
increased at this time. Small quantities of albumen are often found in 
the urine during the first few days after delivery. They are probably 
the result of the muscular exertion of labor, as they are often the result 
of muscular efforts of other kinds. Sugar, too, may be found in small 
quantities in a large proportion of recently delivered women. Acetonuria 
is common, and is probably a starvation anuria, like that of the vomiting 
of pregnancy. To my mind it indicates a more liberal diet than is usually 
allowed. Peptonuria is constant during the lying-in period, and is 
doubtless the result of the absorption of albuminous matter, which is a 
necessary accompaniment of uterine involution. 

On the whole the presence of small amounts of sugar or albumen, 
unaccompanied by symptoms, need not cause alarm at this time. It is 
difficult to secure a clear specimen without the use of the catheter and, 
owing to the danger of cystitis, this is hardly justifiable. 

Probably the products of retrograde change are chiefly excreted by the 
kidneys, although we must not forget that other excretory organs, notably 
the skin, are active at this time. Williams has made the highly interesting 
observation that the usual marked increase in the nitrogen excretion which 
accompanies the early days of the puerperium is absent in patients who 
have been submitted to hysterectomy. 

Lactation. — On the third or fourth day, sometimes a day or two 
earlier or later, the familiar phenomena of lactation are observed. These 
are described elsewhere and need not detain us long. The breasts become 
distended and there are '' prickling " sensations, with moderate pain and 
tenderness, and considerable enlargement of the axillary glands. LTpon 
certain phlegmatic women of a type with which we are all familiar, these 
symptoms make little or no impression. In nervous and hypersensitive 
patients they may be the cause of acute distress. It was formerly supposed 
that the establishment of the milk secretion is physiologically attended by 
fever. This we now know to be untrue. 

In the lower animals milk appears in the breasts at the time of delivery. 
Why is its appearance delayed in the female of the human species? This 
is an interesting question. It has been suggested that the delay is the 
result of natural selection, and is due to the fact that for one reason or 
another the human mother for long periods of time found it inconvenient 
or impracticable to nurse her child immediately after delivery. However 
this may be, it should not be forgotten that the secretion of milk is some- 
times delayed much longer than is usually the case — perhaps until five or 
six days after delivery, as I have myself witnessed. The attendant should 
not be in too much haste to decide that permanent bottle feeding is 
necessary. 
13 



CHAPTER X 
THE MANAGEMENT OF THE PUERPERIUM 

With the expulsion of the placenta and membranes the third stage 
of labor is complete. The puerperium, or lying-in period, has begun. 
Strictly speaking, the puerperium occupies the period extending from the 
end of the third stage until involution is complete, from six to eight 
weeks. Unfortunately the physician usually loses track of his patient long 
before this. Hence the term is usually applied to the period for which 
the patient remains in bed and under the immediate care of her physician, 
two or three weeks, perhaps. It is far better, however, as we shall pres- 
ently see, that the patient be kept under observation until involution is 
complete. 

What can we do to secure for our patient a safe and uninterrupted 
convalescence ? 

Let us assume that the patient has been carefully watched for an hour, 
or better, two hours, after delivery ; that the uterus is well contracted, and 
the pulse and general condition satisfactory. 

Rest and Sleep. — Nothing does a recently delivered woman as much 
good as a few hours of rest and sleep. The room should be darkened, but 
an abundance of fresh air admitted. The patient may see her mother or 
husband for a short time, but anxious and inquisitive friends should be 
excluded. Alatters of dress and appearance, the inspection of the baby, 
etc., should be postponed. She should refrain from much talking, or from 
voluntary muscular effort. I have known a strong and vigorous woman to 
bleed to the point of faintness from disobeying orders and sitting up in 
bed shortly after delivery. Of course, this does not happen often, but 
in the practice of the careful obstetrician it never happens, which is better. 

If the patient is suffering from the effects of hemorrhage or from 
shock, or from extreme weakness, it is wise for her to remain perfectly 
quiet in the dorsal position and with the head low. If, however, there 
is no contra-indication, i.e., if after the lapse of two hours the uterus is 
well contracted, and the pulse good, she may be allowed to turn upon the 
side. In this position she will be much more comfortable and can sleep 
better. As we shall see presently, there is no foundation for the popular 
idea that the patient must remain constantly in the dorsal position, a 
position which soon becomes a species of torture. 

INIeanwhile we should not forget that secondary hemorrhage, while rare, 

does sometimes occur. A watchful nurse should note at intervals the 

patient's general condition, the character of her pulse, the color of her 

face, and the degree of uterine contraction ; and should satisfy herself 

194 



THE MAXAGEAIENT, OF THE PUERPERIUM 



195 



by actual inspection that there is no excessive bleeding — all this with as. 
little disturbance as possible ( Fig-. 135). 

If all this is accounted pedantic and unnecessary, so be it, but it is in 
this way that the patient recovers most quickly from the shock and fatigue 
of labor, and best avoids the danger of hemorrhage and embolism. 

The Prevention of Infection. — A\'hat can be done to prevent infection? 
The danger is greatest during the first few days. At this time the vulva and 
a fresh wound which must be shielded from all septic 





Fig. 135. — Watching the fundus after delivery. 



contact. This is accomplished first, by scrupulous external cleanliness, and 
second, by the avoidance of all internal manipulations. 

The vulvar dressing of sterile gauze, or sterile absorbent cotton, should 
be large enough not only to cover the vulva, but also to fill completely the 
space between the thighs, thus shutting out all possibility of septic contact. 
It should be held snugly in place by a T-bandage, also sterile, pinned to the 
binder if the latter be used. 

Morning and evening, and whenever the dressing is changed after 
urination or defecation, the external parts are freely irrigated from before 
backward with lysol solution poured over the parts from a pitcher; or 
better, the stream from a fountain syringe is allowed to play over the 



196 PREGNANCY, LABOR AND THE PUERPERIUM 

parts. For the first few days all handling and scrubbing should be strictly 
forbidden, as likely to reopen partly healed tears and to convey infection. 
This is especially important when the nurse is untrained and ignorant of 
aseptic technic, as is so often the case. 

During the irrigation the patient lies on her back over the bedpan, and 
when the cleaning process is completed the pad is at once replaced. Some 
physicians and nurses are fond of inspecting the parts to see how the 
healing process is progressing, especially after perineorrhaphy. This prac- 
tice should be emphatically condemned as tending to retard healing and 
to increase the risk of infection. 

Only a slovenly and utterly incompetent nurse will replace a dressing 
that has once been removed for any cause whatever. 

As we shall see directly the strict limitation of the use of the catheter 
and the avoidance of douches, and of all internal manipulations that are 
not strictly indicated, are important in this connection. If sponges are 
used they should be of sterile absorbent cotton, or sterile gauze, soaked in 
lysol solution, and the sponge only, not the fingers, should be permitted to 
touch the parts. 

The Abdominal Binder. — From time immemorial it has been the cus- 
tom to bandage the abdomen of the recently delivered woman. Of late 
this custom has been vigorously attacked and as warmly defended. It has 
been attacked on the ground that it may cause backward displacement of 
the uterus. I believe there is some truth in this assertion. Some writers 
insist that it tends to preserve the figure. This I believe to be a fiction, 
but it is one which is firmly believed by the laity. The idea that it pre- 
vents hemorrhage is of course fallacious. There is no doubt, however, 
that a binder applied after delivery is a source of great comfort to the 
patient. It supports the stretched and relaxed abdominal wall, and per- 
haps, by keeping up intra-abdominal tension, prevents cerebral anaemia. 
The latter may be of importance in cardiac cases. It also permits the 
patient to turn upon her side, without the troublesome sagging of the 
enlarged and heavy uterus, and it afifords a firm support for the attachment 
of the vulvar dressing in front and behind. 

I would sum up the matter in this way. I usually advise the use of a 
moderately firm bandage for the first few days. It is comforting to the 
patient, does no harm, and possibly may do some good. After this the 
patient may dispense with it or not, as she prefers, but if it is worn at all 
it should not be tight enough to make much pressure upon the uterus. 
In this way one secures whatever benefit there may be in its employment 
and avoids any ill effects. It may be well to remind the young practitioner 
that ignorant women and unskilled nurses are apt to attribute all sorts of 
trouble in later life, and especially an ungainly figure, to the omission of 
the binder. I agree with ^^'hitridge ^^'illiams that as far as the preser- 
vation of the figure is concerned the bandage does most good at the end of 
the second week, when the patient first leaves her bed. Bv this time the 



THE MAx\AGEi\IENT OF THE PUERPERIUM 197 

fundus can no longer be felt above the symphysis and a firm abdominal 
bandage can do no harm. 

The bandage usually employed is of unbleached muslin, and extends 
from the trochanters to the false ribs. This suffices while the patient is 
in bed. When the fundus can no longer be felt above the symphysis, 







Fig. 136. — Elastic bandage 20 centimetres wide and 6 metres long. 

an elastic bandage carried several times around the abdomen, or a snugly- 
fitting abdominal supporter, is to be preferred (Fig. 136). 

After Pains. — After pains are the result of the effort of the uterus 
to expel a blood clot. They are not common after first labors, for the 
uterus of a primipara is usually firm and well contracted. The lax 
uterus of a multipara, however, often permits the collection and retention 
of large clots and the patient may have to go through a miniature labor 
to secure their expulsion. The best remedy is ergot ; a drachm at once, 



198 PREGNANCY, LABOR AND THE PUERPERIUM 

followed by one-half drachm every three or four hours, for a day or two. 
If the patient is very sensitive a little paregoric or codeine may be combined 
with the first dose or two of ergot. 

Now and then one meets a case in which the after pains are exception- 
ally severe, quite as severe, indeed, as the pains of labor. I recall the 
case of a patient who had had several attacks of appendicitis but had 
refused operation. In this class of cases the pain is probably due to the 
■dragging of the uterus upon old adhesions in the pelvic or abdominal 
cavity. Here nothing avails but large doses of narcotic medicine. For- 
tunately this class of after pains is not often encountered. Indeed, I am 
not sure that I have seen it described in print, though I have met with two 
or three examples. 

Diet. — The toast and tea system is obsolete, and deservedly so. It is 
a relic of the time when too much depletion was in vogue. A recently 
delivered woman does not need depletion, but rather support. Her con- 
valescence will be more rapid, her strength sooner recovered, she will have 
more and better milk for her baby, and she can better resist infection, 
should it occur, if she have a reasonable amount of good nourishing food. 
No special regimen is necessary. Recalling the first two or three days of 
constipation, and also the fact that patients in bed do not ordinarily require 
as much food as others, we will not urge her to eat simply for the sake 
of eating. Nevertheless, the appetite and desire of a healthy and sensible 
woman is here the best guide. Dyspeptics, however, and those who are 
given to gormandizing and who are fond of sweets and desserts, need 
restraint, or they may contract an attack of acute indigestion, attended by 
iever, and giving rise to much anxiety to the attendant and to the friends 
'of the patient. But these cases are rare. In general, I am accustomed to 
■say to my patients that until the bowels have moved upon the third day, 
they may have any semisolid and easily digested food that they prefer, 
e.g., soups, cereals, weak tea or coffee, and that after that they may eat 
anything they like, excluding, of course, those articles which are notoriously 
indigestible, or which they know from experience disagree with them. I 
think that there is a tendency to give too much milk, thus causing indiges- 
tion and constipation. Doubtless this is due to the popular belief that 
'" milk makes milk," and that the mother who drinks much milk will have 
much milk for her baby ; but there is no evidence that this is the case. If 
the patient is in the habit of taking wine with her meals she may continue 
the practice, but if not, she should not begin the practice at this time. The 
idea that a healthy puerpera needs alcohol to strengthen her is a delusion. 
Our German confreres say that beer should not be used during the lying-in 
period, as it predisposes to hemorrhage, and their opinion must be accepted 
as authoritative. 

A tradition handed down from barbarous times has it that women 
should not be allowed water at this time. This pernicious idea has done 
much harm and caused much unnecessary suffering. If the patient has 



THE :MAXAGEMENT of the PUERPERIUM 199 

retention of urine, or if the breasts are painfully distended and the milk 
supply excessive, it may be wise to restrict the supply of liquid for a short 
time, but as a general rule, cool water should be allowed as the" patient 
desires it. Coilee is said to diminish the supply of milk, and overindulgence 
in this luxury is not to be advised, especially when the milk supply is 
deficient. 

Douches. — It was formerly the custom to give antiseptic douches 
before, during, and after labor, with the idea of destroying germs already 
present in the vagina. This custom has been very generally abandoned, 
and with good reason. In the first place, nature has amply provided 
against infection. The acid mucus of the vagina inhibits bacterial develop- 
ment, and after rupture of the membranes the cervicovaginal canal is 
flooded with liquor amnii, which some one has not inaptly compared to a 
normal salt solution, and, we might add, a sterile one, at that. Moreover, 
the foetus during its emergence is closely embraced at all times by the 
retracting ostium vaginae, so that neither air nor foreign body can enter. 

To these theoretical considerations may be added the fact that it has 
been abundantly shown, both in hospital and private practice, that douches 
are not necessary. This has been my own personal experience in many 
hundreds of cases. To permit untrained nurses to give douches to a 
recently delivered woman, for any reason whatever, is to invite infection. 

Attention to the Bladder. — The use of the catheter should be avoided 
if possible. It is a frequent source of cystitis, pyelitis, etc., and may 
initiate conditions that can never be completely remedied. 

Some physicians leave their patient with the stereotyped advice to the 
nurse, " If the patient does not urinate within six or eight hours use the 
catheter." This is a very serious mistake and is often followed by 
deplorable consequences. 

With proper precautions catheterism is safe enough during pregnancy 
and labor, probably because there are no wounds to infect. After delivery, 
however, the conditions are quite different. The various factors that pre- 
dispose to infection are operative in the urethra as well as in the vagina. 
The urethral mucous membrane has been bruised and lacerated by the 
enormous pressure to which it has been subjected, its resisting power is 
diminished, and the meatus is the seat of multiple abrasions and minute 
lacerations. The vulvovaginal secretions abound in bacteria, including 
the omnipresent colon bacillus, which Alsberg has recently shown to be 
present in the urethra, and lochial decomposition soon begins. 

Under these circumstances it is not strange that catheterism, even 
when performed with the utmost care, often results in disaster. 

If the patient can once be made to urinate by voluntary effort, the subse- 
quent use of the catheter will not be necessary, wdiereas, if the catheter has 
once been passed, it may be necessary to continue its use for days. This 
means much added manipulations of the parts, and vastly increases the 
danger of infection of the birth canal, as well as of the urinary tract. 



200 PREGNANCY, LABOR AND THE PUERPERIUM 

Abundant observation has convinced me that a delay of from twelve 
to eighteen hours does no harm in these cases. Doubtless there are factors, 
perhaps not well understood, which make retention of urine less harmful 
at this time than at others, and I believe that it is better to wait until there 
is positive evidence of distention before interfering. 

Various artifices are known to the experienced nurse. Some of them, 
e.g., the sound of running water, work by suggestion. Hot cloths to the 
abdomen and hot sterile cloths to the vulva may be useful. Very effectual 
is the administration of a large hot enema. Reynolds has made the 
ingenious suggestion that, during the latter weeks of pregnancy, the patient 
accustom herself to urinating in the recumbent position. 

If the patient is in good condition, the pulse slow, and the uterus well 
contracted, and if there is no special contra-indication, it is probably better 
for her to be assisted to a sitting position than to use the catheter. Some 
patients are able to urinate upon their hands and knees. 

In the rare cases in which catheterism is unavoidable, it should be 
performed with every aseptic precaution. This task should be entrusted 
only to a nurse in whom the attendant has entire confidence, and it should 
not be repeated unless necessary. The meatus should be freely exposed 
and the adjacent tissues freed from mucus, etc., by irrigation. Tissues 
about the meatus are then cleansed with lysol or bichloride solution, and 
the catheter passed directly into the meatus under the guidance of the eye. 

Attention to the Bowels. — The traditional dose of castor oil on the 
third day is undoubtedly a good thing for dyspeptics and plethoric subjects, 
but is not always a necessity. With many patients a dose of the milder 
and usually more acceptable effervescent citrate of magnesia or some nat- 
ural mineral water is sufficient. If the bowels have been well opened before 
labor an enema is often all that is needed. The latter has the advantage 
of not disturbing the baby. In obstetrics, as elsewhere, one should be 
guided by common sense rather than by arbitrary rules. On the whole, 
catharsis after delivery is usually overdone, especially in hospitals. Noth- 
ing is more stupid than to give a delicate and anaemic woman, who has 
perhaps had a severe hemorrhage, an enormous dose of castor oil simply as 
a matter of routine, and yet, who has not seen this done? On the other 
hand, an ounce of castor oil, or, if the patient cannot take this, a teaspoonful 
of compound licorice powder, may, in the case of a plethoric patient of 
full habit, or one habitually constipated, be exactly what is needed. After 
the first two or three days the bowels should move at least every other day, 
as long as the patient remains in bed. As a rule, if there is a tendency 
to slight headache, bad taste in the mouth, a coated tongue or accumulation 
of gas in the bowel, or if the patient suffers from habitual constipation, 
laxatives are to be preferred, otherwise enemata. Saline cathartics are, 
as a rule, to be avoided since they tend to weaken the patient and to diminish 
the supply of milk. If, however, there is overdistention, or threatened 
abscess of the breasts, or if it is desired to " dry up " the milk, watery 



THE ^lAXAGE.AIENT OF THE PUERPERIUM 201 

movements are desirable, and salines are indicated. As explained else- 
where it is better that the bowels be not moved too early after extensive 
perineorrhaphies, and especially after the repair of tears of the third 
degree. If an enema is to be given shortly after delivery, or when an 
extensive perineorrhaphy has been performed, it should be given only by 
a skilled nurse, or by the physician himself. Otherwise, the danger of 
infection in the first case, or of disturbance of the stitches in the second, 
is too great. 

Temperature and Pulse. — The temperature and pulse should be taken 
at 8 A.M. and 5 p.m., and at other times whenever it may seem desirable. 
Under ordinary circumstances, however, it is neither necessary nor desir- 
able to disturb a nervous or sensitive patient every few hours for this 
purpose, as is sometimes advised. 

Visits of the Physician.— The physician should see his patient every 
day for the first week and every other day during the second week. More 
frequent visits than this are not usually necessary provided the nurse is 
thoroughly reliable and the case is proceeding normally. At these visits 
he should inquire as to the pulse, temperature, and excretory functions of 
the patient, and should note her demeanor and general condition. He 
should look most carefully after the breasts and nipples, and satisfy himself 
as to their condition by actual inspection. This is a most important matter 
for both mother and child, and we might add, for the physician himself. 

At these visits he should particularly avoid inspecting the vulva or 
perineum, or making local examinations, unless these procedures are 
distinctly indicated, and they seldom are. If not indicated, they do no 
good, and serve only to annoy the patient, to interfere with the healing 
of wounds, and to increase the danger of infection. Some men who 
rigidly exclude visitors forget that they themselves may do harm by their 
unnecessary solicitude. 

He should satisfy himself, if necessary, by actual inspection, as to quan- 
tity and character of the lochia, and especially whether it is excessive in 
amount, or of offensive odor. The first condition might indicate the use of 
ergot, together with an ice-bag over the uterus, and the latter a more 
careful aseptic toilet of the vulva, or perhaps antiseptic vaginal irrigation. 

He should palpate the fundus every two or three days, note whether it 
is gradually and regularly descending, and be prompt to recognize and 
treat any tendency to subinvolution. Too much m.anipulation should be 
avoided, however, as it does no good and is often quite painful. 

The attendant should not forget to note the general condition of his 
patient and to remember that intercurrent affections, though rare at this 
time, do sometimes occur. For this reason he will not fail to investigate 
occasionally the heart, lungs, throat, etc. 

I recall the case of a febrile puerpera who was subjected to a searching- 
examination, which included aspiration of the breast, before it was dis- 
covered that the symptoms were due to an abscess at the root of a tooth. 



202 PREGNANCY, LABOR AND THE PUERPERIUM 

In a word, the careful and judicious physician wiU endeavor at each 
visit to find out all about his patient, with ver>^ little disturbance or manipu- 
lation ; and this he can usually accomplish. 

At these visits the baby should not be neglected. The physician should 
never take the assurance of an untrained or untrustworthy nurse as to the 



Fig. 137- — Dr. Cooke's breast bindtr. 

condition of the child. Especially should he satisfy himself, by actual 
inspection, that the child sucks milk from the breasts and swallows it, and 
by personal investigation, that it is gaining in weight. I have often found 
that the child simply held the nipple in its mouth, getting little or no milk. 
In cases of doubt he should, if possible, secure the services of a skilled 
pediatrist in consultation. 



THE ^lAXAGE^IEXT OE THE PUERPERIUM 



203 



He should never neglect to examine the child for congenital defects, 
to be on his guard against umbilical infection, and to look carefully after 
the child's eyes. All these things take little time, and their neglect may be 
the occasion of bitter regret. Parents, not especially exacting about other 
things, are slow to forgive anv neglect, or supposed neglect, of a child. 

Breasts and Nipples. — In spite of the protests of officious bystanders 
the baby should not be applied to the breasts until the mother has had a 
period of rest. A mature and healthy child needs no food during the 
first twelve to eighteen hours. The motlier needs rest. 

The breast bandage, like the abdominal bandage, is a matter of custom 
and convenience rather than of necessity. If the breasts are large and sag 
heavily, a supporting bandage may afford relief and at the same time help 



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to keep in place the sterile dressings over the nipples. Some patients are 
annoyed by the bandage, especially in hot weather, and in such cases it 
may be dispensed with. If a breast bandage is used, that of Dr. J. B. 
Cooke is perhaps as good as any (Figs. 137 and 138). 

About the third or fourth day after labor, when the milk first appears 
in the breasts, the latter may be much distended and quite tender, especially 
in the neighborhood of the axillae. If the child cannot take enough milk 
to relieve the condition, it is well for the nurse to remove the milk 
by gentle massage after each nursing. In this way the mother is not dis- 
turbed at irregular hours. In place of massage the breast pump may be 
employed, but the former is to be preferred if effective and not extremely 
painful, since it involves less handling of the nipples and therefore less 
danger of infection. 



204 PREGNANCY, LABOR AND THE PUERPERIUM 

After nursing the nipple should be carefully cleansed with a saturated 
solution of boracic acid, dried with sterile absorbent cotton, and kept dry as 
far as possible until the next nursing. Ointments and salves should be 
forbidden since they tend to cause maceration of the nipple, and are seldom 
or never sterile. The patient should not be allowed to touch her nipples, 
and the nurse in washing them should hold the sterile swab soaked in the 
boracic acid solution in such a way as to avoid contact of her fingers 
with the nipple. 

Some advise that the child's mouth be washed before and after each 
nursing. This, I believe, is carrying preventive treatment too far. The 
tender mucous membrane of the child's mouth is easily injured by so much 
handling, and infection is more likely to be caused than prevented, espe- 
cially in hospital practice. In the intervals between nursing the nipples 
should be kept covered with sterile gauze so arranged as to prevent any 
direct pressure. 

Bathing. — The traditions of the lying-in chamber have made this a 
highly important ceremony but as a matter of fact there is no haste about 
it. Indeed, as often practised it does more harm than good. If the eyes 
are clean and the umbilical dressing has been made lege artis, a delay of 
two or three hours does no harm and is probably better for all concerned. 
The tub bath at this time should be unreservedly condemned as a source 
of cord infection and unnecessary exposure. Jacobi long ago made us 
mindful of the danger of exposure and it is self-evident that to bathe the 
umbilical wound in water which, even though sterile at the start, cannot 
long remain so, is to invite infection. 

Any excess of vernix caseosa is best removed, not by soap and water, 
but by sterile albolene or sweet oil. In full-term children or those a few 
days beyond term, there is but little vernix, and its removal is quickly 
and easily accomplished. In the case of premature children the vernix 
is abundant and quite adherent, and if there is much trouble or delay in 
its complete removal it is far better to wait than to spend too much time 
in attempting its complete removal. Great care should be taken not to 
contaminate the umbilical wound or the dressing if this has been applied. 
If a competent nurse is in attendance it will have been wrapped in a 
sterile towel and the dressing of the cord as described above entrusted 
to her. If not, it is necessary that the doctor make it himself before 
opportunity for contamination has been given. 

The proper care of the breasts and nipples, with special reference to 
the prophylaxis of erosions and fissures, and thus, indirectly, of abscess 
of the breast, is one of the most important duties of the accoucheur. 
Abscess of the breast is a painful and disastrous termination of the 
puerperium. Not only does it result in the suspension of nursing with 
perhaps serious or even fatal consequences to the child, but it may destroy 
the functional activity of the breast, and prevent the nursing of future 



THE MAXAGE:\IENT of the PUERPERIUM 205 

children. In the breast as elsewhere infection is more easily prevented 
than cured, ^^'hat measures are to be employed ? 

In the first place let us recall that erosions of the nipple are the result 
of the traumatism involved in nursing. A predisposing cause is maceration 
of the nipple epithelium, the result of too frequent or too prolonged nurs- 
ing. It is obvious, then, that the nipple should be kept as clean and dry 
as possible, and that the direct application of the child's mouth to the 
nipple should be restricted. 

The French seek to avoid maceration of the epithelium by allowing 
the child to nurse but once in three hours. IMy experience has led me 
to believe that many children cannot obtain sufficient nourishment in this 
way, and I prefer (after the establishment of the milk secretion), to adhere 
to the two or two and one-half hour interval, giving 
both mother and child a rest between midnight and 
morning. The breasts should be nursed in alterna- 
tion, and the child should not be allowed to play with 
the nipple, or hold it in the mouth after nursing. 

In sensitive patients, the first efforts at nursing 
produce some smarting and discomfort, which, if 
only moderate and aft'ecting both nipples alike, is of 
no special significance. When, however, the suffer- 
ing is severe, or the patient complains that one nipple 
is more sensitive than the other, erosions, perhaps 
so slight that they can hardly be seen by the naked 
eye, are usually found. 

In these cases I am accustomed to advise p^^, 139.— Nipple shield. 
the use of the glass and rubber nipple shield, thus ^^^* ^i"^- 

removing the cause of the trouble at once. The 

shield should be kept clean, and when not in use should be immersed in 
a saturated solution of boracic acid. It can usually be dispensed with in 
a few days (Fig, 139). 

To insure success in its use, perseverance and attention to detail are 
needed. Some nurses object to the use of the shield because it involves 
too much trouble, or because they have failed at the first trial, or from 
a foolish idea that it is not good for the baby. It is far better for the 
latter to be obliged to use the shield for a few days than to be obliged 
to give up nursing altogether. 

In some cases the rubber nipple is too long and projects into the throat, 
irritating and choking the child and thus preventing satisfactory nursing. 
This can be remedied by pushing the ivory ring (a) nearer the point of the 
nipple. Sometimes the child may be induced to suck by expressing a few 
drops of milk from the breast into the rubber nipple. The mother should 
be turned over almost on her face so that the nipple points downward, thus 
making suction easier. Attention to these seemingly trivial, but really 
important, details is well worth while. 




206 PREGNAXCY, LABOR AND THE PUERPERIUM 

The Care of the New-Born 

Few obstetricians are good pediatrists. It is folly to try to teach 
pediatrics in a work on obstetrics. The field is too large and the responsi- 
bility involved too great. Nevertheless there are certain precautions that 
should be taken in every case and certain common mistakes to be avoided. 
These it may be well to consider here. 

The care of the eyes and the ligation and first dressing of the cord I 
have already considered in connection with the management of labor, to 
which, as I believe, they belong. After these have been attended to the child 
should be made warm and comfortable and laid upon its right side in 
some place where it will be secure from harm and its eyes shielded from 
the light. Here it should remain until the mother has received such 
immediate attention as is necessary. It is well for the nurse to inspect the 
umbilical dressing occasionally in order to see that it is not bleeding and 
to make sure that the child's coverings are so arranged about the face that 
air is not excluded. Children that have been born more or less asphyxiated 
and have been resuscitated with difficulty should be watched closely and 
any change reported at once. Indeed, it is better that the attendant should 
not leave such cases too hastily. ]\Iore than this is not necessary. The 
best thing for the baby at this time is that it be let entirely alone. It is 
too often the case that in the excitement attending the arrival of the long- 
awaited baby the mother is temporarily forgotten and hemorrhage perhaps 
overlooked or aseptic precautions neglected. This is especially apt to be 
so when the case is not in the hands of a competent nurse. 

Clothing. — This is usually the province of the nurse, and will vary 
with the means and tastes of the parents. Only a few hints are necessary 
here. Clothing should be loose and warm. Xo tight bandages ! No 
constriction about the chest. The band about the abdomen should be 
tight enough to keep the umbilical dressing in place and no tighter. Gar- 
ments next to the skin should be of linen or cotton mesh or some similar 
material. These are much more hygienic and cleanly than flannel, absorb 
moisture, and permit the conduction of heat and the free ventilation of the 
skin. Let the doubter experiment with flannel as a diaper or a pocket 
handkerchief and he will be convinced. Of course, the new-born child 
should be kept warm, but an excess of wrappings in hot weather is to say 
the least a useless barbarity. Here as elsewhere it is hardly too much to 
say that the young mother if left to herself will do better to follow the 
instincts of her own common sense than the advice of those about her, of 
ignorant bystanders and untrained nurses. For the details of dress and 
nursery mianagement the reader is referred to Cooke's '' A Nurse's Hand- 
book of Obstetrics '' (last edition, revised by Aliss Gray and Aliss Baker). 

Feeding. — This is by all odds the most important part of the child's 
management, and it is a mistake, I think, to undertake its extended dis- 
cussion in an obstetric text-book. Knowledge thus gained is of necessity 



THE ^lAXAGE^IEXT OF THE PUERPERIUM 207 

imperfect and study of this kind tends to superficial and " short cut " 
methods of investigation. I shall therefore restrict myself to a few words 
on the subject of breast feeding. 

Every new-born baby makes involuntary and automatic movements of 
suction, especially when something is placed in its mouth or brought near 
its lips. These movements are interpreted by the bystanders as meaning 
that the child is hungry and lead to a demand that it be immediately fed. 
As a matter of fact, however, a healthy full-term child needs no food 
at this time and to put it to the breast only serves to deprive the mother 
of her well-earned rest. 

Every mother should nurse her child unless there is some good reason 
why she should not do so. If she cannot nurse her child the ideal substi- 
tute is wet nursing, but there are so many difficulties in the way of securing 
a wet nurse that mixed or bottle feeding is usually the final outcome. If 
a wet nurse is decided upon the physician should be careful as to the 
following points : The child of the wet nurse should be of approximately 
the same age as that of the child to be nursed. The wet nurse should not 
be pregnant, and should be in good health, as proven by painstaking 
examination. In particular, should she be free from tuberculosis and 
syphilis. The Wassermann reaction should on no account be omitted, 
the milk as well as the blood serum being examined. 

The child may be put to the breast after eight or ten hours, and after 
that every four hours for two or three days, or until the milk secretion 
becomes established. One interval at night may be extended to six or 
even eight hours in order to give the mother a good period of restful sleep. 

The Caput Succedaneum. — I have already referred to the moulding 
of the fetal head, a phenomenon with which every practitioner soon 
becomes familiar. Whenever moulding is marked we find at the apex 
of the moulded segment a soft oedematous scalp tumor, the caput 
succedaneum. This represents the most accessible portion of the 
presenting part, or in other words, the portion which is free from 
pressure. This portion swells and becomes the seat of hypersemia and 
serous effusion. 

The tumor thus formed is known as the caput succedaneum (Kopf- 
geschzmlst) . It is most marked in cases of delayed labor and especially 
of dry labor in which the head is subjected to pressure from the beginning. 
It may even occur in cases of delay due to a small and rigid vaginal outlet. 
It does not occur before rupture of the membranes and of course it is 
not found in cases of breech delivery and after the Csesarean section. It 
is important as an indication of delayed labor and sometimes, though 
by no means always, as an indication for operative delivery. A long 
caput may extend far in advance of the head. It may, however, deceive 
the unwary. Now and then one finds what appears to be the occiput 
protruding at the vulva and anticipates delivery within a short time, or 
at least an easy forceps operation. Careful examination, however, or if 



208 PREGNANCY, LABOR AND THE PUERPERIUM 

this is neglected, an attempt with the forceps, shows that the head is 
higher and the case more difficult than was supposed. 

Then, too, the location of the caput as observed after delivery enables 
one to confirm or correct his diagnosis of the position of the head. For 
example, if the occiput is in the left anterior position the caput will be 
on the right parietal bone, and vice versa. Similarly, if the occiput is 
posterior the caput will be farther forward, i.e., in the neighborhood of 
the large fontanelle. 

Cephalhaematoma. — W^hen the conditions that ordinarily produced the 
caput succedaneum are exaggerated there may be a rupture of the blood- 
vessels between the periosteum and the bone with a resulting hsematoma. 
Since the effusion of blood is beneath the periosteum, the tumor cannot, like 
that of the caput succedaneum, extend beyond the border of the bone upon 
which it originates. In other words, it cannot cross a suture. Even when 
there are two h?ematomata, as sometimes happens, each is confined to the 
bone upon which it originates, and a line of demarcation may be easily 
made out. 

Posture in Bed. — Although I usually advise my patients to remain in 
bed for two weeks or more, I believe that it is well to allow them con- 
siderable latitude in the way of position and movement. The ten days' 
dorsal decubitus is a thing of the past. In normal cases with a good pulse 
and a well-contracted uterus there is, after the first few hours, no good 
reason, no good excuse even, for keeping the patient constantly upon her 
back. At this time she can be turned gently upon her side, where she will 
rest much more comfortably and sleep better. Cases of shock or hemor- 
rhage, of course, constitute an exception to this rule. 

There are several good objections to the continued dorsal position. 
The large and heavy uterus sags backward, and it is not unreasonable 
to suppose that subsequent retroversion is thus favored. Then, too, the 
long-continued dorsal position interferes with drainage. Drainage from 
the vagina is favored by the lateral position. This is easily demonstrated. 
If a patient receives a vaginal douche in the dorsal position the solution is 
retained, but if she turns upon her side, the solution runs freely from 
the vagina. 

Sudden movements, or those that require much muscular effort, should 
be prohibited on account of the danger of hemorrhage, or the possibility 
of embolism. 

Toward the end of the first week the patient may sit up in bed for her 
meals, and later she should be advised to assume occasionally the prone 
or semiprone position, thus favoring the normal anteversion of the uterus. 
At the beginning of the third week, if the fundus is no longer felt above 
the symphysis she may be assisted from her bed to an easy chair, where 
she may rest for an hour or two. The period of sitting up may be increased 
by an hour each day, and by the end of the week the patient may be allowed 
the freedom of her room and bath. After this she mav be le-ft to her own 



THE MANAGEMENT OF THE PUERPERIUM 209 

devices, being cautioned to take a nap of an hour or two every day, and 
being told that a backache or a " bearing down " feeling is a signal for 
her to lie down, and. if it does not disappear, to send for her physician. 

Of course all our patients cannot, and some will not, follow this 
regimen. Doubtless there are many cases in which it is not necessary, but 
it can do no harm, and in the great majority of cases it does much good. 

When May the Patient Leave Her Bed. — Every teacher of obstetrics 
frequently hears the question, " How long should the patient remain in 
bed after delivery? " What I have said above seems to me to be a fair 
answer to this question. I am accustomed to add, however, that in any 
case she should not leave her bed until the uterus has descended so far 
into the cavity of the pelvis that the fundus can no longer be felt above 
the symphysis. This varies in different cases. This rule, which was that 
of the late Dr. Garrigues, is to my mind an excellent one, and deserves 
more attention than it has apparently received. After long and tedious 
labors and difficult operative deliveries the period of confinement to bed 
should of course be extended according to the judgment of the physician. 

Some enthusiasts have recently advocated getting the patient up on 
the second or third day after delivery. This proposal has been summarily 
and deservedly rejected by the common sense of the profession. It is 
based, of course, upon the idea that labor is a purely normal, physiological 
process. i\s we have already seen this is theoretically, rather than practi- 
cally, true. Post-graduate students at the New York Polyclinic have often 
told me that among the Indian women who practise this method, dis- 
placement and prolapse are exceedingly common, and death by no means as 
rare as is usually supposed. 

Like other wounds, the wounds that result from labor heal more 
promptly when the patient is at rest. The exact nature of these wounds 
we do not always know. That they are reopened by too early getting up 
is plainly shown by the appearance of the lochia rubra on the tenth day. 
This reopening of puerperal wounds may result in a severe infection, 
especially, as we shall see later, in gonorrhoeal cases. If nothing worse 
happens, the patient will certainly lose more blood by leaving her bed too 
early. Aichel has reported a number of fatal results. I have seen one 
myself — a case of embolism. The patient was permitted to go out on the 
eighth day, and was brought home dead a few minutes later. 

When one recalls the undoubted fact that moderate degrees of phlebitis 
are quite common, and that there is an aseptic thrombosis of the pelvic 
veins that presents no symptoms whatever except, in some cases, a per- 
sistently rapid pulse, the danger at once becomes apparent. 

In many families it is customary to dismiss the nurse as soon as the 
patient is able to leave her bed. This is poor economy. A good nurse 
during the third, and, if possible, during the fourth, week is not only a 
luxury but a great benefit to the patient. The latter usually looks forward 
eagerly to leaving her bed, thinking that her troubles will then be over. 
14 



210 PREGNANCY, LABOR AND THE PUERPERIUM 

As a matter of fact, it is only too often the case that her real troubles 
begin at that time. She has not as yet fully regained her strength. She 
has not only the physical burden of nursing her child, but the new and 
trying responsibility of its general care. She is perhaps harassed by 
household duties and worn out by loss of sleep. The result of all this 
may be a mental and physical depression that leaves its traces years after. 

Final Examination. — It was formerly customary for the physician 
to dismiss his patient as soon as she was able to leave her bed, usually from 
ten days to two or three weeks after her delivery, perhaps not to see her 
again. It is now recognized that the man who adopts this course neglects 
the interests of his patient. 

Before leaving his patient or allowing her to be permanently upon 
her feet the attendant should on no account omit to make a final examina- 
tion for the purpose of determining to what extent, if any, she has been 
injured by the parturient process. 

The task is easy. As we have already seen, the abdominal and pelvic 
tissues are at this time very lax, the enlarged and easily palpable uterus 
freely movable, the appendages easily mapped out. The thinned and 
atrophied abdominal wall makes all the abdominal viscera easily palpable, 
and small tumors, e.g., fibroids, previously unsuspected, are made out with 
the greatest facility. The dilated and relaxed vagina permits the easy 
introduction of the speculum, and the inspection of the cervix and vaginal 
canal. 

Moreover, interest as well as duty dictates that this examination be 
made. For example, it is much better that the attendant himself discover 
a beginning prolapse of the uterus, or a bad tear of the cervix, than that 
the patient's attention should be called to some such disability by another. 

The first thing is to determine the position of the uterus. The exam- 
iner should recall that at this time its normal position is one of marked 
anteflexion. Indeed, it is usually possible to feel the enlarged corpus 
uteri in the anterior ciil de sac before it is depressed by the external hand. 

Backward displacement of the uterus should be treated by reduction, 
and the employment of a retroversion pessary. In this way the danger of 
permanent displacement, or even of prolapse, may often be averted. In 
some cases the condition is the continuation of a backward displace- 
ment existing before pregnancy. This condition is not likely to be cured 
at this time, but is usually amenable to gynaecological treatment later. 

The condition of cervix and perineum may be determined by inspection 
and touch. 

Diastasis of the recti muscles is easily recognized, as are also movable 
kidney, and injuries to the coccyx, sacro-iliac joints and pubic symphysis. 

As Hirst has recently emphasized, all these conditions are amenable to- 
treatment and should be treated. If the attendant feels that he has not 
the requisite experience or facilities, he should secure such surgical or other 
aid as may be necessary. In this way he not only protects the interests 



THE MANAGEMENT OF THE PUERPERIUM 211 

of the patient, but his own as well. It cannot he too strongly stated, hoiv- 
ever, that the attendant is not necessarily responsible for everything that 
happens to a patient, during, or after, delivery. There are some patients 
whose tissues are so friable that they will tear even when the disproportiort 
is moderate and the operator's technic perfect. Now and then subinvolu- 
tion, displacement, cystocele or prolapse will occur, even though tears, if 
present, have been properly repaired, the patient not allowed to leave her 
bed too soon, and the management of the case has been in every respect 
beyond reproach. In these cases the trouble is probably due, as Williams 
suggests, to distention by the presenting part rather than to demonstrable- 
preventable causes. This fact is of the greatest importance from a 
medicolegal point of view. It is unfortunately true that bad obstetrics 
is responsible for much subsequent disability, but it is also true that now 
and then some malicious gossip, or envious colleague, attributes to the 
obstetrician an unhappy result for which he is in no way to blame. 



CHAPTER XI 
MULTIPLE PREGNANCY AND LABOR 

Definition. — When a single act of intercourse results in the production 
of two or more embryos, the resulting pregnancy is known as multiple. In 
practice, multiple pregnancy usually means twin pregnancy, since the birth 
of triplets is a rare phenomenon, witnessed by few, even among those 
largely engaged in obstetrical practice. 

Frequency. — Twin pregnancy is not so very rare, occurring, according 
to reliable statistics, in about one per cent, of all cases. Every physician 
meets, now and then, with a case of twin pregnancy, but there are many 
men largely engaged in obstetrical practice who have never seen the birth 
of triplets, an event which occurs about once in seven thousand cases. 
Many think of the delivery of quadruplets and quintuplets as belonging 
to the realm of fable, but such cases have been authoritatively reported, 
and quadruplets have been known to survive. Vassali even records the 
delivery of six embryos in the fourth month of pregnancy. According 
to Veit triplets are encountered once in 7910 labors, and quadruplets once 
in 371,125. 

Etiology. — Heredity is the only agent of which we have positive 
knowledge. It is undoubtedly true that a tendency to multiple pregnancy 
runs in families. This is a matter of common experience. The tendency 
is usually transmitted by the mother, but occasionally by the father, a fact 
more difficult to explain. Instances of extraordinary fecundity have been 
those in which both father and mother have been members of twin- 
bearing families, as in the case of Boer, in which the father was a triplet 
and the mother a quadruplet. 

Bumm, observing the frequency with which multiple pregnancy is 
associated with certain developmental anomalies, e.g., bicornate uterus, 
polymastia, etc., suggests that it is a form of atavism, a suggestion that 
seems reasonable. According to Duncan, multiparity is a factor, multiple 
pregnancy being less common in primiparae. The statistical researches 
of Williams have led him to believe that it occurs more frequently in cold 
climates, but this is doubtful. 

Development. — Twins may be either, hi-oval, the result of the fer- 
tilization of two separate ova, one from each ovary, or two from one ovary, 
or, uni-oval, the result of the fertilization of one ovum by two spermatozoa. 
Bi-oval twins are found in 85 per cent, of all cases, uni-oval in 15 per cent. 

In the case of bi-oval twins, the two ova usually come from separate 
follicles. Much more rarely, both ova are contained in one follicle. In 
the case of a patient who died from hemorrhage following twin labor, 
Bumm found many follicles containing two ova, and numerous follicles 
containing three. 
212 



MULTIPLE PREGNANCY AND LABOR 



213 



Each bi-oval twin has its own separate and distinct placenta and sac 
of membranes. Sometimes, indeed, the two placentae are so close to each 
other that they appear like one great placenta, btit careful search will 
always disclose the line of separation. Similarly, the membranes may be 



v3\vj:2i^ 




ONE 

AMNIOTIC 

SAC 



^vOVAi 




^vOVAi 




Fig. 140. — Schematic representation of different varieties of multiple pregnancy. 

in such close contact in the median line that on superficial inspection they 
appear as one, but with care four layers, one amnion and one chorion for 
each, may be demonstrated (Fig. 140). 

There has been much difference of opinion among embryologists as 
to the development of uni-oval twins. The discussion of this matter falls 
outside the scope of this work. Full details will be found in text-books 
on embryology. 



214 PREGNANCY, LABOR AND THE PUERPERIUM 

What concerns us more here is that uni-oval twins have one large 
placenta. The two original placentae coalesce to form one organ, homol- 
ogous in structure and function. Each twin, however, usually has its 




Fig. 141. — Twins with communicating circulations. 

own amnion, and of course its own separate amniotic sac. Exceptionally 
there is but one amniotic sac for both. 

Although uni-oval twins have but one placenta, each twin has its own 
separate circulation, the two circulatory systems being connected by an 
arterial and venous anastomosis. In some cases, however, one twin tres- 
passes upon the circulation of its fellow. Thus, if one heart is stronger 



MULTIPLE PREGNANCY AND LABOR 215 

than the other, it may happen that it overpowers the other and becomes the 
head of the entire circulatory system of both twins. The heart of the 
other twin then becomes atrophied from disuse, and with this goes an 
atrophy of the whole body. The result is a monster, the so-called acar- 
diacus. If the child dies it may be compressed by its fellow to the thick- 
ness of parchment (foetus papyraceus) (Figs. 141 and 142). 

Twins often differ very much in size, and, apparently, in period of 
development. This has sometimes been regarded as an evidence of super- 
fetation, but is probably due to dift'erences in placental location, the 
placenta of one twin having a more favorable site for attachment. 

Diagnosis. — The diagnosis of twin pregnancy is not always easy. 
Sometimes it is impossible. 

L'nusual distention of the abdomen is ordinarily the first thing that 
excites suspicion, though this, of course, may be due to other causes, e.g., 
hvdramnion, tumor, or unusual size of the foetus. Now and then a furrow. 




Fig. 142. — Hearts of twins shown in Fig. 141, natural size. 

like that seen in cases of bicornate uterus, may be observed at the fundus. 
Great height of the fundus, as shown by the tape measure, is of consider- 
able importance. It may be over 40 cm. at term. Fabre observed a case 
in which it was 48 cm. There is also a corresponding increase in width 
(Fig. 143). 

Pinard has emphasized the fact that there is a continuous tension or 
pressure resistance in these cases that is very characteristic. On the 
whole, however, external palpation is much less satisfactory than in single 
pregnancy. Twins are usually premature, and much below the average 
in size, the heads are small, soft, and movable, and the other fetal parts 
correspondingly small. Hydramnion is a constant complication, and helps 
to obscure the diagnosis. If four fetal poles, two heads and two breeches, 
or three fetal poles, two heads and one breech, can be made out. the diag- 
nosis is of course positive. But this, for the reasons just given, is 
theoretical rather than practical. 

Sometimes ballottement performed in the usual manner may sen-e to 



216 PREGNANCY, LABOR AND THE PUERPERIUM 

determine the position of one foetus. If now another head can be found, 
either in one iHac fossa or at the fundus, the diagnosis becomes positive. 
Personally I have found this method of considerable value. A seeming 
multiplicity of small parts is a suggestive, but not very reliable, sign. 

On the whole, the most satisfactory sign of twin pregnancy consists 
in the recognition of two fetal hearts, at some distance from each other, 
and beating at different rates. Since the heart-rate varies at different 
times, two men should count simultaneously, and since slight errors in 
counting are unavoidable, the difi"erence should be considerable — ten or 
fifteen beats. 

If the abdominal enlargement is great, and the foetus cannot be outlined, 
the case is probably either one of multiple pregnancy, hydramnion, or very 




Fig. 143. — Height of fundus and circumference at the umbilicus notabh' increased in twin pregnancy. 



thick abdominal wall. The latter of course is easily made out. If it is 
due to pelvic contraction or unusual size of the foetus, external palpation 
will at once settle the matter. If, in a doubtful case, one large and firm 
head can be made out, multiple pregnancy may be excluded, since the heads 
of twins are small and soft. This is a negative sign of decided value. 

Doubtless the X-ray, disclosing two fetal skeletons, will soon give us 
a reliable means of diagnosis. 

A record of multiple pregnancy on either the paternal or maternal 
side increases the probability of its existence. But such evidence is of 
course not positive. 

From all this it is plain that one should be guarded in making the 
diagnosis of twin pregnancy, though it is often easy to show that it does not 
exist. Fortunately an early diagnosis is of no great importance. In 
the majority of cases, the presence of the second twin is not suspected 
until after the delivery of the firsi. Even then it is not always suspected, 
and it has happened many times that the attendant has waited a long time 



MULTIPLE PREGNANCY AND LABOR 217 

for the placenta, only to find that the delay was caused by the presence 
of another twin i)i iitcro, or if the birth of the first twin was followed by. 
the expulsion of its placenta, has gone away unaware of the presence of 
a second child. A word of warning will suffice to put the reader on his 
guard against this ludicrous mistake, which of course could only be the 
result of carelessness. Two amniotic sacs, or a variety of fetal parts 
that could not possibly belong to one foetus, may sometimes be felt upon 
vaginal examination, but this pertains to the diagnosis of multiple labor, 
not of multiple pregnancy. 

The presence of triplets, etc., is not diagnosed until after delivery. 

Clinical History of Multiple Pregnancy. — It goes without saying that 
multiple pregnancy imposes upon the mother greater burdens than does 
single pregnancy. The maternal organism must furnish more nutrifnent 
and oxygen, and there is an enormous amount of nitrogenous material 
to be eliminated. Hence the greater frequency of toxaemia and eclampsia. 

The mechanical disturbances of respiration and circulation may become 
quite serious. Dyspnoea may be severe, and cardiac disturbances, if pres- 
ent, very much aggravated. Varicose veins of the vagina and vulva may 
reach enormous proportions. Fetal movements are multiplied, and may 
become a source of constant annoyance and loss of sleep. Owing to the 
great distention painful contractions are reflexly excited, and may continue 
for days or even weeks before labor begins. Indeed, in these cases it is 
often difficult or impossible to tell when pregnancy ends and labor begins. 

During the latter weeks of pregnancy the canal of the cervix may be 
practically obliterated, and upon vaginal examination the cervix feels 
like that of the first stage of labor. Premature labor is the rule. Twin- 
bearing patients seldom go to term. Hydramrion is so common as to 
constitute a diagnostic feature. 

Clinical Course of Labor.^The first stage is usually prolonged. 
The contractions are painful but ineffectual. This is generally attributed 
to paralysis of the uterine muscle from overdistention. It would seem that 
part of it, at least, is due to the fact that the uterus has to work at a 
mechanical disadvantage, for as soon as the membranes are ruptured the 
contractions are usually sufficient to terminate labor in a short time. 
This is not always the case, however. Quite frequently a true uterine 
inertia does supervene, and the second stage may be prolonged to an extent 
that renders operative delivery necessary. 

If the diagnosis of twin pregnancy has not been made, and this is 
usually the case, the attendant may be at a loss to account for the delay 
in the first stage. These cases are among the most puzzling and trying 
for the young accoucheur. Not knowing the cause of delay he hesitates 
to rupture the membranes and the sufferings of the patient are indefinitely 
prolonged. The cervix does not dilate and the presenting part does not 
descend. 

As soon as the membranes are ruptured, however, a large quantity of 



218 PREGNANCY, LABOR AND THE PUERPERIUM 

liquor amnii escapes, the softened and obliterated cervix rapidly dilates, 
and the presenting part descends into the vagina. This part of the first 
stage presents a vivid contrast to the slow progress that precedes it. 

One of two things may now happen. If the uterus contracts vigor- 
ously, the small foetus is soon expelled, and if the patient is a multipara the 
second stage may occupy but a few minutes. 

But in a considerable proportion of cases good contractions do not 
supervene. The uterine muscle, so long subjected to great distention, does 
not respond. The presenting part remains in the vagina, and the attendant 
again wonders at the delay. 

Thus it happens that operative interference often becomes necessary 
in the second stage of labor. Fortunately for the patient, the small size 
of the foetus makes its extraction easy. 

The delivery of the first child may be followed by the delivery of its 
placenta, as in ordinary labor. This, however, is the exception. In rare 
instances the delivery of the placenta of the second child may precede 
the birth of the latter. In most cases the delivery of both placentae is 
delayed until after the delivery of the second child. 

The birth of the first twin is followed by a period of repose of greater 
or less duration. According to Kleinwachter the second twin is delivered 
in one-half hour or less after the birth of the first, but in exceptional cases 
hours, days, or even weeks, may elapse. 

Owing to the coexisting hydramnion, and to the fact that twins are 
usually of small size, multiple labor is often complicated by malpositions 
and malpresentations. Breech presentation is especially common, but is 
not as unfavorable for the child as in ordinary labor, since the extraction 
of the aftercoming head presents little or no difficulty (Fig. 144). 

The third stage is characterized by a somewhat greater tendency than 
usual to relaxation and hemorrhage, due no doubt to a decrease of the 
tonicity of the uterine muscle, the result of prolonged distention, and, 
perhaps, to the greater area of placental attachment. 

The same causes predispose to subinvolution, and the puerperium is 
usually prolonged. 

Treatment During Pregnancy. — There is little that can be done for 
the discomfort that is so often incidental to twin pregnancy. Special care 
should be taken to guard against toxic symptoms. If the distention is 
extreme the induction of labor may become necessar}^ In this case it is 
unwise to resort to the slower methods, the rubber bag or the bougie. 
They are often ineffectual and the patient is in no condition to endure 
a long first stage and the necessary manipulations. Simple puncture 
of the membranes at once relieves the symptoms and labor follows in a 
short time. The usual objections to premature rupture of the membranes 
do not obtain. 

Management of Labor. — Some writers advise a policy of non-inter- 
ference during the prolonged first stage. This is perhaps wise, if the pains 



^lULTIPLE PREGNANCY AND LABOR 219 

are not too frequent or severe, and if the patient is able to secure some 
sleep. If not, it is better, in my opinion, to terminate labor, since nothing 
more is necessar}- than to rupture the membranes. A prolonged first 
stage here certainly does no good. It is an unnecessary tax upon the 
patient, and strongly increases the already existing tendency to hemorrhage. 
Of course the attendant should be reasonably sure of his diagnosis. 
To rupture the membranes early in a case of pelvic contraction, or of 
unusual size of the foetus, would be a disastrous mistake. If, however, 




Fig. 144. — Twins, one in vertex, the other in breech presentation. (Tarnier and Chantreuil.) 

there is marked distention and the fetal parts cannot easily be made out, 
the case is either one of hydramnion or twin pregnancy, and in either the 
treatment would be the same. 

After rupture of the membranes a short and easy second stage is the 
rule. If, as is sometimes the case, operative delivery becomes necessary, 
it is, owing to the small size of the foetus, almost always easy. Strong 
pressure with both hands over the fundus, after the method of Kristeller, 
often suffices to bring the small head to the floor of the pelvis, or even 



220 



PREGNANCY, LABOR AND THE PUERPERIUAI 



through the vulva. I cannot too strongly emphasize the value of this 
method in these cases. 

In vertex cases the forceps should be preferred to version, since, even 
if the head is high, it can be pushed down within easy reach, and owing 
to its small size no great traction is necessary and there is little compression. 

After the delivery of the first child the maternal as well as the fetal 
end of the cord should be care- 
fully ligated, since, if there 
should be a communication be- 
tween the two placentae the sec- 
ond twin might bleed from the 
cord of the first. 

A careful examination should 
then be made to determine the 
position of the second child, since 
prolapse of the cord or some 
malpresentation may follow the 





Fig. 145. — Locked twins, both in head presen- 
tation. (R. Barnes.) .-1, apex of wedge; BC, 
base of wedge which cannot pass the brim. 



delivery of the 
first. Unless there 
exists some indi- 
cation for deliv- 
ery, e.g., prolapse 
of the cord, or a 
transverse p o s i - 
tion, the delivery 
of the second 
child should not 
be hast e n e d . 
Hemorrhage is 



Fig. 146. — Locked twins, first child partly born in 
breech presentation, the second lodged with the face 
under the chm of the first. (R. Barnes.) •• D, apex of 
wedge; £. C, base of wedge which cannot enter the 
brim; A B, line of decapitation to decompose wedge 
and allow trunk of the first foetus and head of the 
second fcetus to pass. 



less likely to occur if the uterus is not emptied too suddenly. But the fetal 
heart should be carefully watched in the meantime, and if there are any 
indications of impending asphyxia it should be promptly delivered. 

It is not uncommon for the second twin to be retained for hours, and 
many cases are on record in which it has been retained for days, or even 
weeks. This, of course, increases its chances for survival. 

Should the retention of the second foetus be permitted ? If the placenta 
cf the first child is expelled, and if after some hours the condition of the 



MULTIPLE PREGNANCY AND LABOR 



221 



retained fcetus is found to be good as shown by the heart sounds, and if 
the uterus shows a tendency to reconstruct we may temporize, in the hope 
of giving the foetus a better chance. On the other hand, if the placenta 
of the first child is retained, it is obviously unwise to leave it in utero, and 
thus incur the risks of infection and hemorrhage. If, then, at the end of 
an hour the placenta is still undelivered and there are no signs of uterine 
activity it is wise to proceed with delivery. 

Among the rarities that one reads about, but does not see, is the 
interlocking of the heads of twins. As shown in the accompanying illus- 




Fig. 147. — First child presents by the breech. Perforation of after-coming head. 



trations (Figs. 145 and 146) this may happen in two ways. Both heads 
may present, or one head and one breech. 

In the first case a careful attempt may be made to reduce the impaction 
by placing the patient in the Trendelenburg position and introducing the 
hand into the uterus, under full anaesthesia. If this fails, the forceps may 
be applied to the first head and later to the second. If the latter fails, it 
may become necessary to perforate the head of the first child. This child 
is in the greater danger from pressure on the vessels of the neck. 

In the second case, if the impaction cannot be reduced, it is again the 
first child that is in the greatest danger, and it may be possible to decapitate 
it and pnsh the head back, thus making room for the passage of the second. 
This will probably be easier than perforation (Figs. 147 and 148). 



222 PREGNANCY, LABOR AND THE PUERPERIUM 

In either case there is httle chance of the first child having survived 
the pressure and the necessary manipulations, and therefore little chance 
of the perforation of a living child. 

It must be admitted that the directions usually given for the treatment 
of interlocking twins are academic, rather than practical, for the condition 
is so rare that no one has had much experience in its management. In 
one case Lobenstein performed Csesarean section. 

Every care should be taken to prevent uterine relaxation and hemor- 
rhage during the third stage. Ergot should be administered as soon as 
the placentae have been expelled and the patient carefully watched for at 
least two hours thereafter. 

The lying-in period is protracted and more or less subinvolution is 




^//e^ 



Fig. 148. — Twins. Both heads presenting. Perforation of first child. 

the rule. Careful attention is indicated at this time, and the resumption 
of household duties should be delayed longer than in ordinary cases. 

Prognosis 

It is evident that the mother incurs more risk in twin pregnancy. 
Toxaemia and hemorrhage are more common, operative interference more 
often necessary, and convalescence more protracted. Nevertheless, good 
care usually suffices to ward off serious dangers and secure complete 
recovery. 

For the children the prognosis is always serious. The majority are 
more or less premature and the mother seldom has milk enough for both. 
It is well to inform the parents of these facts. 



PART II 

PATHOLOGY OF PREGNANCY AND LABOR 
A. PATHOLOGY OF PREGNANCY 

CHAPTER Xn 

LOCAL DISORDERS OF THE MOTHER 

It is obvious that pathological conditions of the birth canal may inter- 
fere with the normal progress of pregnancy and labor. Sometimes, indeed, 
they may prevent conception. Again, if pregnancy does occur, they may 
unfavorably modify its course, or bring about its premature interruption. 
Then, too. they may delay or complicate labor, or even make delivery 
per z'ias uaturales impossible. 

Endometritis 

Perhaps the most common of these pathological conditions is endo- 
metritis in one form or another. The discussion of this subject falls 
naturally into two divisions, the first dealing with acute inflammatory 
processes, usually the result of infection during or after labor or abortion, 
the second, with chronic conditions, which, strictly speaking, are degenera- 
tive rather than inflammatory, and which often, though not always, prevent 
the development of pregnancy. Infections following labor, or more rarely 
occurring during labor (intrapartum infections), are discussed in the- 
section on puerperal infection. 

The endemotritis of syphilis, a local manifestation of a general disease, 
and the endometritis of gonorrhoea are discussed in connection with those 
subjects. 

AA'ith the exception of the endometritis of syphilis, a local manifestation 
of a general disease, to be considered in the next chapter, endometritis, 
occurring during pregnancy is the result or continuation of a process ante- 
dating pregnancy, and is essentially chronic. That a latent gonorrhoea, 
existing before pregnancy, may be awakened to full activity and take on 
acute symptoms as a result of the stimulus of conception, as claimed 
by some writers, has not been proven. Gonorrhoea as a complication of 
pregnancy, labor and the puerperium will be separately considered. 

Acute decidual endometritis then is a rarity during pregnancy. The 
chronic form, however, is by no means rare at this time. The different 
forms are grouped under the name of chronic decidual endometritis. 
Taken together, they constitute a common cause of abortion, and present 
a group of symptoms which, from a diagnostic and therapeutic stand-point,. 
are highly important. 

223 



224 



PATHOLOGY OF PREGNANCY AND LABOR 



The changes are mainly hypertrophic in character, and consist in a 
general thickening and hyperplasia of the mucous membrane. This 
appears to take the place of the normal decidual atrophy that occurs after 
the first few months of pregnancy. When the condition is general and 
symmetrical it is called diftuse. In some cases the general hypertrophy 
and hyperplasia are slight but there are patches of polypoid growth scat- 
tered here and there over the decidual surfaces. This is the classical 
polypoid endometritis of A^irchow. Again the changes are most marked 
in the decidual glands, and are accompanied by an accumulation of watery 
fluid between the vera and reflexa, or, much more rarely between the reflexa 



Abnormal secretion 

of amnion and 

chorion 



Secretion from diseased 
decidua 




True liquor amnii 



Fig. 149. — Diagram showing the different kinds of liquor amnii. 



and chorion or between the latter and the amnion. This condition is 
otherwise known as hydrorrhoea gravidarum. It has a special clinical 
interest in that the watery discharges by which it is characterized often 
lead the physician or nurse to believe that there has been a premature 
rupture of the membranes. This may prove a serious mistake. Not every 
watery discharge that occurs during pregnancy represents a rupture of 
the amniotic sac. How often one hears from nurse or patient that the 
membranes have ruptured and yet finds on examination that such is not 
the case. The sources of error are well shown in Fig. 149, from Bumm. 
White infarcts and other changes in the placenta may be due to changes 
in the decidua serotina, placental endometritis. 



LOCAL DISORDERS OF THE MOTHER 



225 



Hegar and others have described a condition of decidual atrophy, 
atrophic decidual endometritis (Figs. 150 and 151). 



a 







<i. 







^y^:. 



■'^ 



Fig. 150. — Interstitial inflammation of the decidua. (Emanuel.) a, wedge-shaped infiltration with 
small round cells; h, enlarged glands; c, small blood-vessels; d, glands. 




Fig. 151.— Endometritis tuberosa and polyposa. (Bulius.) 



Clinical History. — Occasional pain in the back or abdomen may or 
may not be present. The most prominent and constant symptom, however, 
is the discharge from the vagina. This is usually of a reddish-brown 
15 



226 PATHOLOGY OF PREGNANCY AND LABOR 

color and slight or moderate in amount. In the glandular variety it is 
usually profuse in quantity and with no intermingling of red. It may 
continue for weeks, or throughout pregnancy. 

Prognosis. — The prognosis in these cases relates, of course, chiefly 
to the foetus. Doubtless many abortions are due to endometritis, the cause 
not being recognized unless the expelled decidua is examined microscopi- 
cally. If, however, the patient weathers the first few months of pregnancy 
successfully, all may be well in the end. The attendant should never 
give up hope in these cases. With good management one occasionally 
secures a living child when least expecting it. 

Diagnosis. — Decidual endometritis is sometimes mistaken for placenta 
praevia, but in the latter condition the discharge is bright red while in 
endometritis it is brownish and watery. 

It might also be mistaken for haematuria, but the use of the catheter 
suffices for the distinction. 

The possibility of cancer of the cervix should not be overlooked. There 
is usually a history of endometritis antedating pregnancy. 

Treatment. — Every effort should be made to put the patient in good 
physical condition by good diet, fresh air and tonics, especially iron if 
indicated. All sources of mental and physical overstrain should be sedu- 
lously avoided, and the prophylactic treatment of abortion, elsewhere dis- 
cussed, carried out in every detail. Experience has convinced me that the 
fluidextract of viburnum prunifolium is useful in these cases. Its efficacy 
is perhaps increased by combining it with an equal quantity of the fluid- 
extract of hydrastis. 

Of course local treatment is not available during pregnancy, but after 
delivery a thorough curettage often results in the cure of the condition. 

Granular Vaginitis (Colpitis Granulosa) 

This is of common occurrence during pregnancy. It is of some clinical 
importance, since the affected parts are less succulent and therefore dilate 
more slowly and tear more easily than under normal conditions. More- 
over, such tears are more likely to become infected, and healing is imperfect 
or altogether absent. 

The condition is characterized by a profuse discharge and a charac- 
teristic rough granular " feel," due to the presence of enlarged papillse 
of the vaginal mucous membrane. 

Emphysematous colpitis (Colpitis emphysematosa) was first de- 
scribed by Winckel. It is peculiar to pregnancy, or, at all events, is seldom 
observed at other times. This curious condition is characterized by the 
presence in the vaginal mucous membrane of the cedema bacillus of 
Lindenthal. 

V ulvitis 

Owing to the eversion of the vulva, even the lower vaginal wai'is pro- 
truding more or less, and to the increased congestion and rnoisture of the 



LOCAL DISORDERS OF THE MOTHER 227 

parts, a mild catarrhal, and even a granular vulvitis is common. It ma}^ 
be accompanied by condylomata. A common causative factor is lack of 
cleanliness. ^Ivcosis vulvae, a fungoid intiammation much resembling the 
'* thrush " of young infants, and characterized, like that affection, by the 
presence of thin grayish patches, is sometimes noted. 

Diagnosis. — These affections are often mistaken for gonorrhoea on 
account of the profuse discharge and especially of the condylomata. The 
diagnosis can only be made by repeated bacteriological examination. 

Treatment. — As a rule cleanliness, i.e., plenty of soap and water exter- 
nally, is sufficient. In aggravated cases of vaginitis mild astringent 
injections may be used, only in skilful and careful hands. For mycosis 
vulvae a 20 per cent, solution of silver nitrate is useful. 

GONORRHCEA 

This aft'ection, occurring as a complication of pregnancy, is unfor- 
tunately common enough, especially in hospital practice in our large cities. 
The subject is an important one, commonly neglected, and deserves special 
attention. 

As a rule, the process is present in a chronic or subacute form, and 
represents the continuation of a process antedating pregnancy. Often 
innocently acquired, and presenting no acute symptoms, its existence is 
usually unsuspected by the patient. Nor in the absence of a microscopical 
examination is the physician in a position to affirm or deny its existence. 
Its only symptom is an increased leucorrhoeal discharge, and such a dis- 
charge is common enough in uncomplicated pregnancy. It may be neces- 
sary to make several examinations before the gonococcus is found. 

yiore rarely an acute gonorrhoea is contracted during pregnancy. In 
my experience this is more frequently observed in hospital practice. Here, 
as in syphilitic and chancroidal lesions, the increased blood supply of the 
parts leads to an exaggeration of the local evidences of the condition. 
The bright red, almost scarlet, color of the mucous membrane, in contrast 
with the abundant milky discharge, makes a characteristic picture familiar 
to the maternity hospital interne, and one is almost safe in making the 
diagnosis without the microscope. To these objective signs are added the 
usual symptoms of urethritis. 

Strange as at first thought it might seem, gonorrhoea does not greatly 
modify the course of pregnancy. The gonococci do not ascend beyond the 
cervix ; at least this is the general rule. After delivery, however, conditions 
are quite different. The decidual barrier has been removed, the cervix is 
widely dilated, and even though the patient may have escaped serious 
injury, a multitude of minute tears and abrasions offer as many avenues 
for the spread of infection. Moreover the lochial discharge makes an 
ideal culture medium for the bacteria. 

Thus it happens that the gonococci do not usually find their way into 
the uterus until after delivery, and the majority of patients date the begin- 



228 PATHOLOGY OF PREGNANCY AND LABOR 

ning of their troubles from this time. Tubal and ovarian disease often 
result and subsequent sterility is common. Every physician soon becomes 
familiar with the fact that women not infrequently abort and subsequently 
become invalids after marriage, or, more often, after the birth of the first 
child. 

Treatment During Pregnancy. — Leaving aside the possibility of the 
occurrence of abortion, gonorrhoea is still a most undesirable complication 
of pregnancy, since it may cause: i. Infection of the child's eyes durmg 
labor. 2. Infection of the mother during labor, or more commonly during 
the puerperium. 

Hence it follows that the affection should be treated during pregnancy. 
For this purpose vaginal douches are commonly used. This treatment has 
never seemed to me sufficiently radical to accomplish much. J\Iy own 
custom is to insert into the vagina and well up against the cervix through 
a speculum a tampon of sterile absorbent cotton soaked in a solution of 
silver nitrate twenty grains to the ounce. After an hour or two the patient 
herself may withdraw the tampon by means of the attached string. This 
method, which I learned years ago from the late Dr. \\\ R. Pryor, usually 
results in a prompt cessation of the discharge, and while it may not effect 
a radical cure, undoubtedly diminishes the danger to both mother and child. 
Moreover, it is easily carried out and does not disturb the patient or have 
any tendency to interrupt labor. The latter cannot be said of vaginal 
douches, especially if administered in a careless and routine manner. 

The prophylaxis of ophthalmia neonatorum is one of the most impor- 
tant duties of the obstetrician, but at the same time he should not forget the 
possibility of the contraction of the disease (gonorrhoeal ophthalmia) by 
his assistants. House physicians and nurses should be warned of the 
danger and should be required, not requested, to wear rubber gloves, and 
to use every possible precaution. We have all seen occasional sad examples 
of the neglect of this rule. 

Labor should be conducted as far as possible without internal examina- 
tions, and one should try to avoid the introduction of the finger within 
the cervix. Operative interference should be practised only in the presence 
of a distinct and imperative indication. All this of course to prevent the 
transmission of the gonococci to the cavity of the uterus. 

Similar precautions should be observed during the third stage. Douches 
and internal examinations should be forbidden and the proper management 
of the third stage, as given on p. 172, carefully followed out. 

It is a matter of common observation that gonorrhoeal infection is 
usually first manifest shortly after the patient leaves her bed. x\t this 
time partly healed tears are reopened and the ascent of the gonococci 
facilitated. In view of this fact Bumm has advised that these patients be 
kept in bed, avoiding all unnecessary movements, during the entire period 
of involution, or, in other words, five or six weeks. Perhaps this is 
hardly practicable, or absolutely necessary, but I have been in the habit 



LOCAL DISORDERS OF THE AIOTHER 229 

of advising my patients to remain quietly in bed for at least three weeks. 
I recall a private case in which I expressly warned the patient and her 
family of the necessity of absolute rest. The patient, who was not aware 
of her condition, was persuaded by her mother to leave her bed a few 
days after delivery, and on my next visit I found her suffering from high 
fever and severe abdominal pain. The cause was found when, alarmed at 
her condition, she confessed that my instructions had been disregarded. 
The prophylactic treatment of the child's eyes should on no account 
be omitted. This consists in the instillation into each eye of one or two 
drops of a one per cent, solution of silver nitrate. Subsequent irrigation 
with salt solution is unnecessary. In view of the demonstrated harmless- 
ness of this procedure, and of the possible consequences of its neglect, I 
am in the habit of advising its routine practice. Having found the silver 
nitrate ver\^ effectual. I still continue its use in preference to that of the 
newer preparations of silver. 

Tumors 

Xext in order of frequency as disturbing elements in the course of 
pregnancy and labor come the various morbid growths. The reader 
should not consider them merely as mechanical obstacles to the progress 
of pregnancy and labor. This is indeed an important, perhaps the most 
important, eft'ect of their presence, but its importance is entirely dependent 
upon their size or location. As we go on we shall see that the mere presence 
of a neoplasm may, irrespective of size or location, affect the integrity 
and growth of the uterine structure, thus causing various bad results, e.g., 
sterility, abortion, deficient uterine contraction with its corollaries, delayed 
labor, hemorrhage, retention of the placenta, etc., and, in the puerperium, 
infection and subinvolution. 

So far as the mechanical effect of these growths is concerned, we may 
say in a general way that they affect the course of pregnancy more when 
located above the brim of the pelvis, in which position they may increase 
the abdominal distention and encroach upon the space required for the 
growth and development of the foetus. Their effect upon the progress 
of labor, however, is practically nil. On the contrary, when located 
within the pelvis and firmly fixed, a tumor of only moderate size may 
render natural delivery difffcult or impossible. 

MYOMATA (fibroids) 

Among the new growths that may give trouble in this connection, the 
myomata, or fibroids, as they are commonly called (Figs. 152 and 153), 
take the most important place because of their frequent occurrence. The 
prognosis in these cases, however, is not as bad as was formerly supposed, 
and the mere presence of a fibroid affords no excuse, per sc, for a resort 
to heroic surgery and no ground for great apprehension. It has been 
the occasional experience of every obstetrician to find, while palpating the 



230 



PATHOLOGY OF PREGXAXCY AND LABOR 



uterus after delivery, one or more fibroids whose existence had not 
previously been suspected, and which had given rise to no symptoms 
whatever. I recall finding one in the course of a Csesarean section. 

When, however, abdominal tumors are large enough to cause much 
distention, or when pelvic tumors are of sutficient size to obstruct delivery, 
there may be a very different story to tell. 

It is well to recall the fact that the existence of fibromata may prevent 
conception, and that the preventive treatment, to be discussed presently, 
should not be forgotten. It is a well-known fact that submucous fibroids 
and also interstitial fibroids that encroach upon the uterine cavity are 




Fig. 152. — Retrocervical fibromyoma filling the pelvis. Caesarean section at term. (Spiegelberg.) 

often, though not always, accompanied by an endometritis which may 
prevent conception, or, if conception does occur, may lead to abortion. 
On the other hand, subperitoneal, or even interstitial growths that do not 
encroach upon the uterine cavity, do not act as a bar to conception. 

How does the presence of fibromata affect the course of pregnancy? 
If they are small or of moderate size, and especially if they are of the 
subperitoneal variety, not at all. Even considerable invasion of the body 
of the uterus by interstitial growths does not always prevent conception 
and the completion of pregnancy. 

In the case of very large tumors there is often irregular bleeding which 
helps to obscure the diagnosis, and abortion and premature labor are more 



LOCAL DISORDERS OF THE MOTHER 



231 



common than in uncomplicated pregnancy, though not as much so as might 
be expected. In some cases, happily not very common, the distention is 
too great to be borne. ]\Iyomata grow very rapidly during pregnancy and, 
if the tumor is very large, the combination of growing uterus and growing 
tumor may cause severe pressure symptoms, e.g.. pain, dyspnoea, and 
interference with the return circulation, that imperatively demand relief. 
Sometimes the symptoms are less acute, consisting of heaviness and dis- 
comfort in the abdomen, and marked oedema of the feet and legs, espe- 
cially at night. The cause of the rapid growth of myomata during 
pregnancy is doubtless to be found in the congestion and serous infiltration 
common to all the pelvic structures at that time. In some cases the tumors 




Fig. 153.— Fibrous polypus of cervix occupying the vagina. (Toison.) 

become softened and the infiltration of serum between the ultimate 
muscular elements of the tumor results in the formation of cysts which 
serve to obscure the diagnosis, the operator perhaps thinking that he has 
to deal with a cyst of the ovary; a strange parallel to the fact that an 
ovarian cyst confined in the pelvis may, by the pressure to which it is 
subjected, acquire a stony hardness which leads the examiner to believe 
that it is a fibroid. Montgomery has observed cases in which severe pain 
attended partial rotation of the uterus caused by the presence of large 
tumors in the anterior and posterior walls. 

What is the effect of these growths upon the progress of labor? 
Abdominal tumors do not usually constitute a serious obstacle to the 
progress of labor. In the majority of cases they do not interfere with it 
at all. In some cases, however, probably in those of extensive interstitial 
involvement, the uterine muscle is incompetent for its task, the con- 



232 PATHOLOGY OF PREGNANCY AND L.\BOR 

tractions are weak and ineffectual, and labor is delayed. Then, too, 
tumors that encroach to any great extent upon the uterine cavity naturally 
result in the production of malpresentations, e.g., those of the breech. On 
the whole, however, these complications are rare. As long as there is no 
great change in the size or shape of the uterine cavity, subperitoneal 
growths, even if numerous and of considerable size, are usually quite 
harmless ; and by some wonderful provision of nature, even extensive 
interstitial degeneration does not always interfere with the normal progress 
of labor (Figs. 152 and 153). 

There is more likely to be trouble in the third stage. If there is much 
involvement of the uterine wall, the lack of contractile power may result 
in retention of the placenta or hemorrhage or both. In these cases manual 
removal of the placenta may be necessary. If hemorrhage occurs no time 
should be wasted in useless efforts to secure uterine contraction, but the 
uterus should be promptly and thoroughly packed. I recall a case of this 
kind which terminated fatally before my arrival. 'My impression at the 
time was that had the placenta been promptly removed, and the uterus 
packed, the unfortunate ending might have been averted. Necroses of the 
tumor, from pressure of the fetal head during prolonged labor or operative 
deliver}' with resulting sepsis, are a possibility not to be forgotten. This, 
however, is usually evidence that delivery should have been accomplished 
by other means. 

As might be expected, involution proceeds more slowly and the puer- 
peral period is prolonged, but as though to compensate for this, the 
growths themselves sometimes undergo a kind of involution and practi- 
cally disappear. A fibroid as large as the fetal head has been known to 
disappear, and thus permit a subsequent labor to proceed normally. 

Tumors that occupy the pelvic cavity, however, may constitute an 
insuperable obstacle to delivery per vias uatiirales. In the case of these 
tumors one can never tell in advance what the course of labor will be. 
They are the tumeurs a surprise of the French writers. ^lany of them 
are drawn up above the brim by the retraction of the lower uterine segment 
that forms part of the first stage. Others can be dislodged by cautious 
manipulation. AMth some reduction cannot be accomplished without the 
use of dangerous force. 

Tumors of the cervax, if of any size, are sure to cause dystocia, since 
they cannot rise above the pelvic brim. They are doubly undesirable, 
because they not only obstruct delivery, but interfere with cervical dila- 
tation. If the tumor happens to have a long pedicle it may be pushed out 
before the fetal head. This, however, is rare. 

Tumors of the broad ligament are unfavorable, because, being fixed 
by adhesions, they cannot ascend above the pelvic brim. Interstitial 
growths of the posterior wall, when situated low down, are very apt to be 
caught below the promontory of the sacrum, and to constitute a serious 
bar to delivery. 



LOCAL DISORDERS OF THE MOTHER 233 

\>ry rarely a rapidly growing tumor occupying the pelvic cavity may 
become incarcerated below the brim of the pelvis. Tumor and uterus 
together form a mass so large that it cannot rise above the brim of the 
pelvis. The condition is attended by persistent abdominal pain and 
obstinate constipation. If not relieved it can only progress to a fatal 
termination. 

Diagnosis. — The diagnosis of abdominal tumors is not always easy, 
even in the second half of pregnancy. The situation is further confused 
bv the fact that menstruation, or at least an irregular bleeding often 
mistaken for menstruation, continues. 

The rapid increase in size of the tumor is significant. No other tumor 
grows as fast as does the pregnant uterus, and when pregnancy and tumor 
coexist, this rapidity is sometimes astonishing. 

The breast changes are of no great value here, since they may be 
present in any condition in which the uterus becomes enlarged and con- 
gested. This is also true of Chadwick's sign, and other evidences of local 
congestion. IMuch more suggestive are the subjective symptoms, morning 
sickness, etc., and the history as given by an intelligent patient. 

In experienced hands the best results are obtained by external palpation 
and by auscultation. Owing to the presence of the tumor it may 
be impossible to map out the fetal parts or even to determine the fetal 
position, which, as might be supposed, is often abnormal. The recognition, 
however, of fetal movements, or fetal heart sounds, by a competent 
observer is final. 

When the tumor is in the pelvic cavity the diagnosis is easy. Even 
when the tumor cannot be separated from the uterus and definitely 
mapped out, the extreme hardness of the lower uterine segment gives a 
sensation entirely different from that of the boggy softness of the nor- 
mally pregnant uterus. The softened cervix projects like a nipple, as 
DeLee says, presenting a vivid contrast to the surface from which it 
springs. External examination is easier, and with care the positive signs 
of pregnancy can be elicited. 

Treatment. — This is best considered under three heads : 

1. The prophylactic treatment, i.e., the surgical or other treatment 
of those patients who, being the subjects of fibroid growth, desire to 
become, or are likely to become, pregnant. 

2. The treatment during pregnancy. 

3. The treatment during labor. 

The prophylactic treatment is a subject of importance, but one gener- 
ally neglected. Although pregnancy complicated by the existence of 
fibroids usually terminates fortunately, there are many exceptions to this 
rule, and the danger is sufficiently great to warrant surgical interference 
whenever the location or size of the tumor is such as would be likelv to 
disturb the course of pregnancy or labor, or when the tumor, whatever 
its size or location, is productive of symptoms. In my experience small 



234 PATHOLOGY OF PREGNANCY AND LABOR 

subperitoneal growths of the body and fundus are very common, have 
no special significance, and need no special treatment. 

The operation selected will of course depend upon the circumstances 
attending the individual case. ^Montgomery reports a case in which he 
enucleated thirteen interstitial growths, the patient becoming pregnant 
nineteen months later and being delivered of a healthy child without serious 
mishap. This of course is an extreme case but serves to show what can 
be accomplished. 

Treatment During Pregnancy. — In the great majority of cases an 
expectant plan should be followed. The induction of abortion, formerly 
practised in the hope of avoiding possible dangers and complications, is 
not advisable, since in many cases the process cannot be satisfactorily 
completed. Bitter experience has shown that removal of the secundines 
is often difficult and that hemorrhage and sepsis are common. The 
myomatous uterus does not contract well. 

If hemorrhage, severe pain or marked pressure symptoms offer a 
positive indication for interference, the patient should be removed to a 
hospital and placed under the care of a thoroughly competent operator. 
If the symptoms are due to the incarceration of a pelvic tumor a very 
cautious effort at reduction should be made under anesthesia and with 
the patient in the Trendelenburg position. The effort should not be long 
continued, and the exercise of much force is likely to result in disaster. 

If this attempt fails, and in all cases in which the symptoms are 
apparently due to an abdominal tumor, the abdomen should be opened 
and the case treated according to indications. Strangely enough operative 
procedures do not, as in the case of ovarian cysts, appear to increase the 
tendency to abortion, and the ample blood supply of the pregnant uterus 
promotes the rapid repair of operative wounds. Therefore, if the child 
is not viable and the removal of the tumor appears to be attended by no 
great danger to the mother, excision or enucleation should be performed 
according to indications. If, on the other hand, the required operation 
will seriously imperil the mother's life, hysterectomy should be performed. 

If the child is viable it should be removed by Csesarean section, after 
which the tumor is removed or hysterectomy performed according to 
indications. 

Treatment During Labor. — If there is no pelvic obstruction, the 
treatment should be expectant, the attendant bearing in mind the some- 
what increased probability of malpresentations, of hemorrhage, and of 
placental retention. Usually there is no need of active treatment (Fig. 154). 

If there is a pelvic tumor that is apparently so large and so firmly 
fixed as to make delivery improbable or very difficult, the Csesarean section 
should be performed and followed by the removal of the uterus, or by 
excision or enucleation of the tumor, according to circumstances. I recall 
a case in which continued bleeding from the site of the uterine incision 
made necessary the removal of the uterus. Fortunately this is not common. 



LOCAL DISORDERS OF THE MOTHER 



235 



In the case of a single tumor, whose removal promises to be easy, it is 
better to avoid hysterectomy, since the latter operation is attended by 
more shock. If, however, the uterus is honeycombed with interstitial 
growths, its removal is undoubtedly the safer procedure (Fig. 155). 

If the tumor is of moderate size, causing only partial obstruction, the 
case should be watched for a time in the hope that with the progress of 
cervical dilatation and uterine retraction, it may rise above the pelvic brim. 



Myomatous 

nodules at 

fundus 




Occiput 



Cervix 



Fig. 154. — Large myoma obstructing pelvic inlet. 



If this does not occur, a cautious effort at reposition may be made as 
already described. 

If the attempt at reposition fails, as it is very likely to do, if cervical 
dilatation ceases and spontaneous delivery seems improbable, and if the 
child is living and viable, the question arises whether it shall be delivered 
per vaginam by means of version or the forceps, or whether Cassarean 
section shall be performed. Unless the obstruction is comparatively slight, 
the latter operation is to be preferred. With modern methods it is 



236 



PATHOLOGY OF PREGNANCY AND LABOR 



decidedly less dangerous both to mother and child, than an attempt to 
drag the foetus through the obstructed birth canal. If the foetus is dead, 
embryotomy should be promptly performed. 

Pediculated tumors that are accessible should be extirpated as soon 
as possible. 

During the third stage the physician should be on his guard against 
hemorrhage and retention of the secundines. As already noted, hemor- 
rhage should be treated by the prompt and thorough application of the 



Myomatous 
nodules 
at fundus 




Fig. 155- — Same uterus as Fig. 154 during period of dilatation. 

Uterine tampon. During the puerperium hemorrhage is diminished and 
involution promoted by the administration of small but repeated doses of 
ergot; fifteen or twenty drops of the Huidextract three or four times a day. 



OVARIAX CYSTS 



Cysts of the ovary are much less frequent during pregnancy than the 
fibromata. This is fortunate, for an ovarian cyst constitutes a much more 
serious complication than does a fibroma. Not only is abortion much more 



LOCAL DISORDERS OF THE MOTHER 



237 



frequent, but certain serious accidents are likely to occur. Among these 
are torsion of the pedicle, rupture of the cyst, intracystic hemorrhage, 
infection of the cystic contents, and pressure symptoms similar to those 
already considered in connection with fibromata (Fig. 156). 

Diagnosis. — AMien the tumor occupies the abdominal cavity the diag- 
nosis is somewhat more difficult than in the case of the fibromata which, 
owing to their hardness, can be more easily differentiated from the uterus 
proper. A large ovarian cyst with its fluid contents resembles the preg- 
nant uterus with its contained liquor amnii. The combination of such a 
cvst with pregnancy has led to the diagnosis of hydramnion or twin 




Fig. 156. — Head arrested at brim by an ovarian cyst. (Tarnier and Budin.) 

pregnancy. Small pediculated cysts are more easily made out. There is 
usually a history of amenorrhoea. 

When the tumor occupies the pelvic cavity it is easily made out but, 
owing to the pressure to which it is subjected, it may be so hard as to 
simulate a fibroid. 

Effect Upon Pregnancy and Labor. — Leaving aside the accidents 
mentioned above, the mere presence of an abdominal cyst has little or no 
effect upon the course of pregnancy. Nor is the course of labor materially 
influenced. H, however, a cyst occupies the pelvic cavity, it may, of course, 
prove an obstacle to delivery. Owing probably to the traumatism of labor, 
infection of the cystic contents is quite common. 

Treatment During Pregnancy. — As a rule it is better to remove the 
affected ovary as soon as the diagnosis is positive. To this it has been 



238 PATHOLOGY OF PREGNANCY AND LABOR 

objected that abortion follows the operation in twenty per cent, of cases. 
It occurs, however, in seventeen per cent, of the non-operative cases, and 
in view of the accidents that threaten both fetal and maternal life, the 
difference is not marked. 

To this rule, however, as to most rules, certain exceptions may be 
admitted : for example, if the patient is childless and elects that pregnancy 
shall continue, after its risks have been fully and fairly stated, or when 
the other ovary is affected, and there is no hope of another pregnancy. 
If pregnancy has advanced to the seventh month one might venture to let it 
go on a month longer in order to secure a viable foetus. 

According to Jeannin there is one case in which it is better to defer 
the operation for reasons purely surgical, vis., when the pregnancy has 
gone on to six or seven months and the cyst is confined below the pelvic 
brim. In such a case the presence of the gravid uterus makes the removal 
of the cyst a matter of great difficulty, and it is better to allow the patient 
to go to term, when the conservative Csesarean section may be performed 
and the tumor removed. 

In the few cases in which it seems permissible to defer the operation 
the patient should be placed in a good hospital, or, at least, under strict 
and constant surgical observation. 

In ovariotomy performed during pregnancy the uterus should be 
handled as little as possible and full doses of morphine should be given 
hypodermically in order to prevent abortion. 

Treatment During Labor. — If the cyst is in the abdominal cavity, 
the management of labor does not differ from that which obtains in 
uncomplicated cases. 

If it is located in the pelvis a very gentle effort at reduction may be 
allowed. For this purpose the patient is placed in the Trendelenburg 
position, and the fetal head gently lifted upward and out of the way. 
Only the most gentle efforts are permissible, and if they fail no attempt 
should be made to drag the head past the tumor, even though the dis- 
proportion be slight. All rough handling of the tumor is prone to cause 
bruising or rupture with resulting infection. The Caesarean section should 
be practised unless infection is already present, or the patient's general 
condition is so poor as to contra-indicate an abdominal section. In such 
cases the tumor should be removed by the vaginal route. 

During the puerperium the patient should be narrowly watched and the 
tumor removed at the first indication of trouble. 

Cancer of the Cervix L^teri 

This is the most formidable complication of all. Fortunately it is rare, 
occurring only about once in two thousand cases. The patients are usually 
between thirty and forty years of age. The symptoms and diagnosis are 
the same as in the non-pregnant condition, differing in degree rather than 
in kind. Owing to the serous infiltration and increased blood supply, the 



LOCAL DISORDERS OF THE MOTHER 



239 



disease pursues a more rapid course. Hence the great importance of 
early recognition. The lirst symptom is the appearance of a bloody or 
oti'ensive discharge. As we have seen in connection with placenta pr^evia. 
such a symptom should never be neglected. Owing to the rapid spread 
of the disease the general condition deteriorates rapidly. The cachexia 
is pronounced and the debility progressive. Hemorrhage is more promi- 
nent than in the non-pregnant state. Premature interruption of pregnancy 
occurs in two-thirds of the cases (Bar). 

Treatment During Pregnancy. — The treatment to be adopted depends 
upon the stage of advancement. In other words, upon whether the cancer 
is operable or inoperable. 

If the disease has not extended beyond the cervix, if in the judgment 




Fig. 157. — Retroflexion of the gravid uterus. (Swytzer.) 



of an experienced gynaecologist there is a reasonable hope of saving the 
life of the mother, hysterectomy should be performed and the operation 
should be as radical as is consistent with her safety. If the child is viable 
it should of course be delivered by Csesarean section before the uterus 
is removed. 

If the case is inoperable, the only task left the accoucheur is the 
melancholy one of keeping the mother in as good condition as possible in 
order that she may at least live to give birth to her child. At the end 
she is delivered per vias naturalcs, or by the Csesarean section, according 
to circumstances. 

Treatment During Labor. — If the disease is in its initial stage and 
the cancerous infiltration is slight, spontaneous labor may occur, or delivery 



240 PATHOLOGY OF PREGNANCY AND LABOR 

may be accomplished by forceps or version. In the first stage of labor, 
therefore, the treatment should be expectant. The attendant should watch 
the progress of labor, and especially of cervical dilatation. If dilatation 
does not occur after a reasonable time die Csesarean section should be 
performed, and followed by hysterectomy. Attempts at manual or instru- 
mental dilatation are dangerous in these cases. The infiltrated and hard- 
ened tissues tear easily, and serious or even fatal hemorrhage may result. 

In addition to the neoplasms mentioned above there are various unusual 
forms of obstruction that do not admit of classification and to some of 
which we have referred elsewhere. Among these are solid tumors of the 
ovary, cancerous growths in the bladder or rectum, vesical calculi, etc. 

The kidney has been known to become prolapsed and obstruct the. 
progress of labor. Obstruction from an extra-uterine pregnancy coexisting 
with a normal pregnancy is a rare and curious phenomenon. 

Obstruction from echinococcus cysts, and from old masses of inflam- 
matory exudate, have been observed. Pelvic tumors, e.g., osteosarco- 
mata, exostoses, etc., are discussed in the section on pelvic contraction. 

In all these cases the general principles of treatment are the same, 
but the details will vary with the individual case. In a general way it 
may be said that any operable tumor which promises to prove a serious 
obstruction should, except for good reasons to the contrary, be removed 
during pregnancy, and that inoperable tumors should be left until the 
beg^inning of labor, when the Csesarean section should be performed and 
followed by hysterectomy or such other surgical treatment as seems best 
to fit the circumstances of the case. 

Retroversion and Retroflexion of the Gravid Uterus 

As we have already noted, marked anteversion is the normal position 
of the pregnant uterus. In the exceptional cases in which it is retroverted 
or retroflexed, it is found in the hollow of the sacrum and its ascent may 
be hindered by the projecting promontory. 

Frequency and Etiology. — This accident is one to which the text- 
books devote much attention, but which, at least in its aggravated form, 
is very rare in America. It may, however, be an occasional and usually 
unrecognized cause of abortion, and especially of abortions occurring in 
successive pregnancies and always at about the same time, i.e., during the 
second or third month. It appears to be much more frequent in central 
Europe, probably because of the greater frequency of contracted pelvis. 
Long standing, as in the case of patients whose household cares allow 
them little time for rest, is a predisposing cause. The constant pressure 
of the abdominal contents is a factor in preventing the ascent of the 
fundus. In some cases the descent of the fundus is prevented by 
inflammatory adhesions. 

As a rule the retrodeviation of the uterus antedates pregnancy, though 
instances of its occurrence during pregnancy as the result of traumatism 
have been reported. 



LOCAL DISORDERS OF THE MOTHER 



241 



Terminations. — Ordinarily the natural forces are sufficient to over- 
come the difficulty. The contractions of the anterior wall are sufficient to 
draw up the body of the uterus, the cervix meanwhile being '' stemmed " 
against the symphysis, which serves as a fulcrum (Chrobak). Reduction 
is much more likely to occur in cases of retroflexion than in those of 
retroversion, since the long, comparatively straight uterus of retroversion 




Cervix 

drawn up 
anteriorly. 



Fig 



Retroflexed uterus, partially replaced at end of pregnancy. 



not only occupies more space anteroposteriorly, but catches above the 
symphysis in front, and below the promontory behind. 

In some cases, fortunately rare, the obstruction is too great and the 
uterus becomes incarcerated below the promontory. Three results may 
now follow : 

The patient may abort. 

Partial reposition (sacculation) may occur. 

The uterus may become incarcerated beneath the promontory. 

A word is necessary here as to what is meant by partial reposition or 
16 



242 



PATHOLOGY OF PREGNANCY AND LABOR 



sacculation. Here the posterior wall of the uterus remains adherent in 
the pelvis, and the anterior wall is stretched upward in a manner analogous 
to that which obtains in cases of anterior fixation. Under these circum- 
stances the symptoms are much milder and it may even happen that preg- 
nancy will continue. In this condition, however, the cervix is drawn 
up anteriorly instead of posteriorly, and the presenting part in the pelvis 
distends the posterior not the anterior wall. The condition is made clear 
in Fig. 158. 




Fig. 159. — Pushing up the incarcerated uterus, with aid of knee-chest position. 

Clinical History. — The earlier symptoms are often disregarded, and 
the physician is usually first consulted during the fourth or fifth month, 
on account of painful urination or retention of urine. The former 
symptom may be the result of an acute gonorrhoea, but the latter is very 
rare in early pregnancy, and the attendant should always search carefully 
for the cause. In these cases it is at once disclosed by vaginal examina- 
tion. The finger at once comes upon the corpus uteri distending the 
posterior cul de sac and perhaps pressing upon the vaginal wall and 



LOCAL DISORDERS OF THE ^lOTHER 243 

rectum so as completely to obstruct the passage of f?eces. The cervix, not 
felt at first, is found far up anteriorly behind or even above the symphysis. 

In neglected cases the familiar symptoms of paralysis from overdis- 
tention soon follow. There is abdominal pain and swelling together with 
dribbling of ammoniacal urine. The bladder may reach to the umbilicus. 
If the condition is still unrelieved, rupture or gangrene of the bladder 
may develop, and death from exhaustion or sepsis ensue. 

Prognosis. — This is good if the complication is discovered early and 
treated properly. Neglected cases usually involve the loss of the child 
and serious danger to the mother. 

Treatment. — The first thing to do is to empty the bladder. For this 
the ordinary catheter may not suffice, since the urethra and neck of the 
bladder are enormously stretched. A prostatic catheter, or a long English 
webbing male catheter, may succeed. The passage of the catheter may 
be facilitated by drawing the cervix downward and backward with the 
volsellum. 

The bladder having been emptied, an effort is made to push the uterus 
upward and backward, at the same time guiding it a little to one side of 
the promontory if necessary. Here again assistance may be afforded by 
drawing the cervix downward and backward. Before resorting to anaes- 
thesia, reposition should be attempted with the patient in the knee-chest 
position (Fig, 159). 

After the uterus has been replaced it should be kept in position by a 
vaginal tampon, or by a globe or ring pessary. 

If attempts at reposition fail, and if there are no evidences of infection 
or gangrene, laparotomy may be performed and the uterus lifted above 
the brim, adhesions being separated if necessary. If, however, the con- 
ditions are unfavorable for laparotomy, abortion becomes the only resource. 
This may sometimes be accomplished by rupturing the membranes with a 
highly curved sound. In some cases, however, especially in retroversion 
when the cervix may point directly upward, this cannot be accomplished. 
In this emergency one may adopt the method of puncturing the body of the 
uterus at its most prominent part with an aspirating needle of medium 
size and allowing the amniotic fluid to drain away. The uterus grows 
rapidly smaller and is easily replaced. Strangely enough abortion does 
not always follow, Bumm observed one case in which pregnancy contin- 
ued until term and terminated normally. 

Severe dystocia has also followed the Mackenrodt operation of vaginal 
fixation in a large proportion of cases, and it seems clear that this and 
similar operations should be proscribed during the lying-in period (Fio-. 
160). 

During pregnancy treatment can be only palliative. Toward the end 
anodynes may be needed. 

In labor the treatment depends altogether upon the location and 
condition of the cervix. If the latter can be reached and drawn down 



244 



PATHOLOGY OF PREGNANCY AND LABOR 



without great difficulty, and this is usually the case, delivery can probably 
be effected per vias iiatiirales. If not, the Cesarean section is to be 
preferred. 

Prolapse of the L^terus 
Prolapse of the pregnant uterus is encountered now and then by every 
worker in the field of obstetrics. Conception may occur before complete 
prolapse, or after. As has been frequently shown, even complete prolapse 
is not necessarily a bar to conception. More commonly, however, there is 
already a prolapse of the second degree, and the increased weight of the 
uterus of early pregnancy helps to make the prolapse complete. 




Copyright, 1912, D. Appleton &. Co. 

Fig. 160. — Dystocia following ventre suspension. (After Williams.) 

In the great majority of cases spontaneous reposition occurs by the 
end of the seventh month. At this time the uterus has become too large 
to escape below the brim of the pelvis. Complete prolapse at the end of 
pregnancy is an impossible condition. Sometimes one sees the cervix pro- 
truding from the vagina at this time, and the clinical picture reminds one 
of complete prolapse, but the real condition is one of incomplete prolapse 
with hypertrophy of the cervix. Strangely enough, the condition does not 
complicate labor to any great extent. With, the retraction of the uterus 
the cervix is drawn up over the head and disappears from view, not to 
be seen ag-ain until after labor. 



LOCAL DISORDERS OF THE MOTHER 245 

In exceptional cases the uterus becomes incarcerated below the pelvic 
brim. Here nature usually comes to the rescue and the incarceration is 
relieved bv the expulsion of the uterine contents. Cases of persistent 
incarceration, Avith gangrene of the uterus, have, however, been reported. 

Treatment. — In early pregnancy the patient should avoid standing 
and should remain in bed. or at least in the recumbent position, several 



\ 



i 



Fig. i6i. — Prolapsed pregnant uterus. (Wagner.) 

hours a day. If the prolapse is marked the uterus should be supported 
by a pessary. Owing to the weight of the uterus and the relaxation of the 
pelvic floor, ordinary pessaries are useless or injurious. Excellent results 
are obtained, however, by the use of a cup pessary, which is attached 
to a belt worn about the waist (Fig. i6i). 

Persistent incarceration demands the immediate emptying of the 
uterus. 



246 



PATHOLOGY OF PREGXA^XY AND LABOR 



Hernia of the Pregnant Uterus 

In rare instances the pregnant uterus has found its way into the sac of 
an inguinal or umbilical hernia, or more commonly between the recH 
muscle (ventral hernia). A one-horned uterus easily finds its way into 
the sac of an inguinal hernia (Figs. 162 and 163 ). 

Treatment. — There is little on record with reference to the treatment. 
Prudent attempts at reposition are indicated. In one case Winckel 
performed Caesarean section. 




Fig. 



-Pregnant uterus in sac of inguinal hernia. (Winckel.) 



Structural Anomalies of the Uterus 

It is self-evident that structural anomalies of the uterus may modify 
the course of pregnancy and labor. Fortunately such anomalies are of 
infrequent occurrence. We will recall here a few of the most common. 

double uterus (uterus duplex) 
The reader will recall that the uterus and vagina are the product of the 
union of the two ^Miillerian ducts. When this union either in whole or in 
part fails to occur, various forms of double uterus or double vagina, or 
both, may result. As obstetric complications they are of comparatively 
rare occurrence. The uterus arcuatus, by which is meant a uterus with 
a visible fissure or depression at the fundus, is quite common, and serves 



LOCAL DISORDERS OF THE MOTHER 247 

hardly any other purpose than to remind us of the developmental origin 

of the uterus, or now and then to suggest the possibility of twin pregnancy. 

The following varieties are of clinical importance (Figs. 164-170) : 

UTERUS DIDELPHYS 

Here there has been no coalescence of the ^liillerian ducts at all, and 
as a result we find two uteri entirely separate from each other. These 
uteri, however, are not complete. Each uterus, or, more correctly speaking, 
half uterus, has its own Fallopian tube and round ligament, and each its 
own cervix, but the vagina may or may not be double (Fig. 171). 





FxG. 163. — Diastasis of recti muscles with hernia of pregnant uterus. (Adams.) 
UTERUS BICORNIS 

In the case of this anomaly the ducts of Miiller have not been com- 
pletely separated and the uterus, while divided into two parts or " horns " 
above, is practically one cavity below, or, at most, divided into two parts 
by a septum more or less complete. There may be one cervix or two. As 
a rule there is but one vagina. 

UTERUS UNICORNIS 

If one of the ducts of Miiller is absent the result is the so-called uterus 
unicornis, a long half-uterus, curving outward at the top and ending in a 
point. Along with the tsterus unicornis there may be a rudimentary horn 



248 



PATHOLOGY OF PREGNANCY AND LABOR 



having as a rule no connection with the uterus, but yet, as we shall 
presently see, capable of containing the product of conception. 

Diagnosis. — This is often difficult. Palpation may show an exagger- 




FlG. 164. — Uterus Unicornis. 




Fig. 165. — Uterus Pseudo-Didelphys. 



Fig. 166.— Uterus Bicornis Duplex. 




Fig. 167. — Uterus Bicornis Septus. 




Fig. 168. — Uterus Bicornis Subseptus. 




Fig. 170. — Uterus Bicornis Unicollis with 
Fig. 169. — Uterus Bicornis Unicollis. Rudimentary Horn. 

Figs. 164-170. — Diagrams of uterine malformations. (Kehrer.) 

ated uterus arcuatus, i.e., a deep cleft in the middle of the fundus ; or in 
the case of the uterus unicornis, the extreme lateral obliquity of the uterus 
together with the absence of a typical fundus. These signs, especially the 



LOCAL DISORDERS OF THE MOTHER 



249 



tirst. are suggestive, if present, but are often absent. Careful bimanual 
examination may reveal an empty horn. Double cervix and double 
vagina, if present, are, of course, highly suggestive. 

Clinical History. — Pregnancy in a double uterus does not, as might at 
first be supposed, necessarily lead to disaster. In many cases the double 




Fig. 171. — Uterus duplex separatus, or uterus didelphys. (Nagel.) i, right tube; 2, right ovary; 
3, right uterus, in which the foetus was developed; 4, rectovesical ligament; 5, left ovary; 6, left tube; 
7, left uterus with decidua; 8, left vagina; 9, vaginal septum; 10, right vagina. 



Uterus is not discovered until the patient has passed through one or more 
uneventful labors. L^terine inertia and hemorrhage are, however, some- 
what more common than under normal conditions, since the uterine muscle 
is not fully developed. Hemorrhage is especially to be feared when the 
placenta is developed upon the thin septum which separates the two cavities 
of a double uterus. 



250 PATHOLOGY OF PREGXA\XY AXD LABOR 

AMien there is pregnancy in one-half of the uterus there is hyper- 
trophy of muscle and mucous membrane in the other, but no decidual 
development. ^ Owing- partly to the irregular asymmetrical development of 
the uterus, and partly to the fact that the unimpregnated but hypertrophied 
fellow-uterus may prove an obstruction, there is an increased tendency to 
malpositions and malpresentations, and to placental retention. The latter 
complication is also favored, of course, by the defective muscular power 
of the organ. 

In the uterus unicornis pregnancy and labor usually run an uneventful 
course. 

Uterus with a Rudimentary Horn 

Of all the malformations this possesses the greatest clinical significance. 
The horn may communicate freely with the uterus, but this is the excep- 
tion. Usually there is no hope of natural delivery ; the spermatozoa may 
enter but only to fertilize an ovum which later finds no way of escape 
aside from rupture of the horn. Oftentimes there is no apparent means 
by which the spermatozoa can reach the horn at all. In these cases, it is 
conjectured that they pass through the Fallopian tube of the developed 
uterus to the fimbriated extremity, and here fertilize an ovum which 
wanders across the peritoneal cavity and enters the tube of the opposite 
side, or that the spermatozoon may wander alone to the ovary of the 
opposite side, and here fertilize an ovum, which later finds its way into the 
tube, and eventually into the cavity of the rudimentary horn. 

Diagnosis. — The condition is often, indeed usually, mistaken for extra- 
uterine pregnancy ; but since the treatment is practically the same, this is 
no great misfortune. There is, however, one means of diagnosis which is 
available whenever the round ligaments can be felt. The ligament of the 
rudimentary horn runs inward instead of outward, as is normally the case, 
and as is the case with the developed uterus of the other side. As in extra- 
uterine pregnancy, however, the diagnosis is usually first made after the 
abdomen has been opened. 

Prognosis. — This is good if suitable treatment is instituted in time. 
Otherwise it is exceedingly grave since, as in extra-uterine pregnancy, 
rupture almost always occurs, and may be followed by profuse and 
perhaps fatal hemorrhage. 

Treatment. — This can consist only in laparotomy and the removal of 
the rudimentary horn, together with the product of conception. 

Atresia of \^ulva, Vagina or Cervix 

An imperforate hymen now and then requires incision. A hymen 
apparently absolutely intact may yet contain a minute aperture through 
wdiich the spermatozoa may penetrate. 

Atresia of the vulva is very rare. It has been known to follow in- 
flammation attending the exanthemata, and deep ulceration occurring in 



LOCAL DISORDERS OF THE MOTHER 251 

the course of puerperal infection. It may also result from traumatism, 
and like similar conditions elsewhere may be of congenital origin. 

Atresia of the vagina results from similar causes. Complete atresia is 
almost always congenital. Traumatism may be the result of an ill-fitting 
pessary, or of clumsy work with the forceps. Cicatricial bands may be 
either circular or longitudinal. 

Atresia of the cervix in the form of simple agglutination of the ex- 
ternal OS or even absence of the os, is not a very formidable complication 
as we shall see directly. Marked atresia, however, involving the body of 
the cervix, and perhaps the internal os, is usually either congenital, or the 
result of traumatism attending difficult delivery. 




>/0 



\ 



Fig. 172. — Episiotomy. 

Treatment. — Stenosis or atresia of the vulva usually requires nothing 
more than a modified dilatation with the fingers or perhaps with a colpeu- 
rynter. \^ery rarely incisions may be necessary ; a modified episiotomy 
( Fig. 172). hxi imperforate hymen is treated by incisions radiating from 
the centre. 

Atresia of the vagina is treated in the same way. Circular constric- 
tions may require multiple small incisions. If the obstruction is very 
marked it is better to perform Csesarean section than to make deep 
incisions which may extend indefinitely during the process of delivery. 

Mere agglutination of the external os is easily dealt with. A dimple 
usually marks the location, and the finger or some blunt pointed instnmient 
is then introduced. Dilatation follows with surprising rapidity. If the 



252 PATHOLOGY OF PREGNANCY AND LABOR 

dimple is absent, a small crucial incision at the corresponding point suffices. 

Stenosis and even congenital stricture of the cervix usually yield to 
the forces of nature. The idea that cicatricial tissue will not dilate does 
not apply to these cases. The congestion, softening and infiltration of 
pregnancy work wonders. Even when the cervix is a mass of cicatricial 
tissue it may dilate contrary to all expectation. If the obstruction is too 
great anterior vaginal hysterotomy may suffice, but if the child is of full 
size, or the patient a primipara, and if conditions are favorable, abdominal 
Caesarean section is to be preferred. 

So-called rigidity of the cervix is discussed where it belongs, i.e., in 
connection with the subject of delayed labor. It is well to repeat here, 
however, that the cervix dilates most easily when the patient is at full 
term. This is also true, though in a lesser degree, of both the vagina and 
vulva. 

Cystocele and rectocele, although made much of in the text-books, are 
of theoretical rather than practical interest in this connection. They can, 
in my experience, be pushed back without trouble. In the case of a 
cystocele the bladder must first be emptied by the catheter. 



CHAPTER XIII 
GENERAL DISORDERS OF THE MOTHER 

Preeclamptic Tox.emia. Eclampsia. The Vomiting of Pregnancy. 
Acute Yellow Atrophy of the Liver. Chorea Gravidarum 

Pathological conditions affecting the mother during pregnancy fall 
Tiaturally into two divisions : first, those which are caused by pregnancy 
and are. of course, pecuhar to that condition, and second, those which have 
nothing to do with pregnancy per se, but occur simply as complications. 
Those which are inseparable from pregnancy are, of course, most 
distinctive and typical, and will be first considered. 

During pregnancy the maternal organism must provide not only for 
ordinary physiological necessities, but for the upbuilding and development 
of the foetus. Xew tissue must be constructed and waste products of fetal 
and placental metabolism must be disposed of. The mother must provide 
for the necessities of the foetus. The latter has been aptly compared to a 
parasite, which takes what it needs, and leaves what it does not need, for 
the mother. 

As a rule, the wonderful resources of nature are sufficient for the task. 
Not always, however. We need not wonder that the weaker parts of the 
organism sometimes break down ; that many patients show the eff'ect of 
the tax imposed by their extra burden. The anaemia and malnutrition so 
often observed in early pregnancy, even in the case of patients enjoying 
fairly good health, are only too characteristic. 

Until we know more of the mysteries of organic life and development, 
we will not be able to tell just how or why the existence of pregnancy 
causes or favors the development of the morbid conditions which we are 
about to consider. Some of them are plausibly explained as toxaemias, 
other as neuroses, and so on. These explanations are often based upon 
assumptions or hypotheses that cannot be absolutely verified. 

Nevertheless modern methods of classification, while still hypothetical 
and subject to revision, afford a better working basis than the old. 

Most characteristic are the so-called toxaemias. These I am accus- 
tomed to divide into: i. Preeclamptic toxaemia. 2. The vomiting of 
pregnancy. 3. Irregular and unclassified toxaemias. 

Some writers speak of a nephritic toxaemia, but nephritis, like pneu- 
monia and other diseases that may coexist with or complicate pregnancy. 
is a clinical entity in itself and has nothing to do with pregnancy per se. 

Of the toxaemias of pregnancy the most frequent, and therefore from a 
clinical stand-point the most important, is preeclamptic toxaemia, commonly 
but less appropriately termed the toxaemia of pregnancy, or the kidney of 
pregnancy, or again, the albuminuria of pregnancy. The term kidney of 

253 



254 PATHOLOGY OF PREGNA^XY AND LABOR 

pregnancy is an unfortunate one because it tends to identify the condition 
with nephritis, and the same statement is true of the term albuminuria of 
pregnancy. The term toxaemia of pregnancy is preferable, since it does 
not attempt to define a condition the cause of which is not yet regarded as 
definitely settled, but there are other toxaemias that may occur during 
pregnancy. On the whole, the best term is preeclamptic toxaemia. This 
identifies the condition, even if it does not explain it, since we know that in 
the vast majority of cases, if not in all, it is the forerunner of eclampsia. 
Moreover, the use of this term serves to remind us of the vast importance 
of the timely recognition and treatment of the condition, as a means tc^ 
the prevention of eclampsia, the most formidable complication with which, 
the obstetrician has to deal. 

The subject of preeclamptic toxaemia is one of the most important in 
the whole range of obstetrics. ^lost writers devote much space and time 
to eclampsia, and little to preeclamptic toxaemia. In my opinion this 
should be reversed. Eclampsia, in most cases at least, is easily prevented. 
In the present state of our knowledge it is not easily cured. Here, as so 
often elsewhere in obstetrics, prophylaxis is of prime importance. Every 
obstetrician who appreciates the responsibility of his calling should 
familiarize himself with the symptoms of this condition, should search for 
them in every case, and, having found them, should lose no time in the 
institution of suitable measures of relief. What are these symptoms? 

Clinical History. — The condition is distinctively one of the latter 
months of pregnancy. Its symptoms soon become familiar to every ob- 
servant practitioner. Similar symptoms occurring early in pregnancy 
usually indicate nephritis, which is to be sharply dififerentiated from 
preeclamptic toxaemia. 

They are best considered under four heads : i. Those referred to the 
urinary secretion. 2. Those referred to the circulatory system. 3. Those 
referred to the nervous system. 4. Those referred to the digestive system. 

True, this classification of symptoms is empirical rather than scientific. 
For example, the nausea probably has nothing to do with the stomach,. 
per se, but is of toxic origin, the headache is of toxic rather than nervous 
origin, etc., but in my experience it affords an excellent method of 
refreshing the memory in going over a case clinically. 

The most definite and characteristic symptoms are those which are 
shown by urinalysis and of these albuminuria comes first. The presence 
of albumen during pregnancy, even though the amount be slight, should 
always excite the keen attention of the physician. And this especially if 
the albuminuria is constant, i.e., if it is found at repeated examinations. 

Writers of the last generation were wont to say that a slight albuminuria 
is normally present in most pregnancies and is to be regarded as a harmless 
phenomenon. It is true that we occasionally see a transient or intermittent 
albuminuria that is unaccompanied by symptoms. A transient albumi- 
nuria may occur after a hearty meal, or after some unusual exertion, just as 



GENERAL DISORDERS OF THE MOTHER 255 

it may in the non-pregnant condition, and, indeed, just as it usually does 
immediately after labor. Perhaps it is a little more common in pregnancy, 
though this has not been my observation. 

Bumm and other German writers attribute the occasional slight inter- 
mittent albuminuria, which is also unattended by symptoms, to a catarrhal 
inflammation of the bladder, which, they state, is quite common during 
pregnancy. Strictly speaking the condition is one of congestion rather 
than inflammation, and the albuminuria is due to transudation through the 
congested mucous membrane of the bladder. Then again, it may be due to 
the contamination of the specimen by some vaginal discharge. 

Personally, I believe that the frequency of these causal factors is often 
exaggerated. ^Nlany times the accompanying toxaemia is overlooked because 
the patient seems in fair health and it is taken for granted that no serious 
trouble can be impending. If a careful examination were always made 
in these cases of slight albuminuria some traces of toxaemia, e.g., a rise in 
the blood pressure, or a little oedema of the ankles, would usually be found. 

It is safest to regard every case of albuminuria occurring in the latter 
half of pregnancy as one of toxaemia, and to treat it as such, unless the 
presence of the albumen can be definitely accounted for in some other way. 
In doubtful cases the urine should be drawn with a catheter, after careful 
cleansing of the parts. 

In the mild cases there is no great amount of kidney debris, though a 
few hyaline casts may be present. 

Xow and then the physician is called to a case in which the urine is 
decreased in quantity and contains large c[uantities of albumen, together 
with granular and epithelial casts, but in these cases the other clinical evi- 
dences of toxaemia are too plain to be overlooked. 

Some years ago certain enthusiastic writers startled the medical world 
by the assertion that a low urea output is a precursor of eclampsia and the 
most significant symptom of the preeclamptic toxaemia. How many labors 
were unnecessarily induced as a result of the rash acceptance of this dictum 
will never be known. Personally, I soon became satisfied that such teach- 
ing was incorrect. Examining the urine of outpatients at the New York 
Polyclinic I found that the urea output might be astonishingly low in cases 
that were to all appearances absolutely normal. Many other observers 
reached the same conclusion, while still others pointed out that the excre- 
tion of urea is no index of the patient's condition, unless the amount of 
nitrogenous food consumed is also definitely ascertained. Moreover, it 
was soon found that, for some as yet unexplained reason, pregnant women 
excrete less urea than those who are not pregnant. 

More recently, various investigators have claimed that a better index 
to the prognosis is found by a study of the now familiar " nitrogen parti- 
tion," i.e., by the relative amounts of nitrogen eliminated as ammonia and 
as urea. There is good authority for the statement that in grave toxcxmia, 
not only is the total percentage of urea much decreased, but that the relative 



256 PATHOLOGY OF PREGNANXY AXD LABOR 

amount of nitrogen excreted as ammonia is relatively increased. This kind 
of analysis, however, requires two or three days for its completion, and is 
quite beyond the resources of any one who is not a good analytical chemist. 
Moreover, it is expensive and there are many sources of error. 

Soudern believes that acidosis precedes the other urinary changes in 
toxaemia and his statement certainly corresponds with what we know of 
nitrogenous metabolism in these cases. L'nfortunately this acidosis is 
usually overlooked. 

But we should not be satisfied with the chemical analysis of the urine. 
The quantity should always be noted. So great is the inertia of custom 
and habit that one often sees cases in which the attendant has contented 
himself with simply testing the urine for albumen without asking as to 
the quantity. During the latter part of pregnancy the patient should be 
questioned upon this subject from time to time even if no evidences of 
toxaemia have been observed, and in all cases of doubt the urine should be 
carefully measured. A pregnant woman, taking a normal amount of 
liquids, should pass not less than sixty ounces per day, and any considerable 
fall below this amount should be made the subject of investigation. 

For the general practitioner then, far removed from laboratories, and 
working, often to his great credit, among the poor, the determination of the 
presence and the approximate amount of albumen, the presence and 
variety of casts, and the measurement of the total quantity of the urine, 
will remain the chief available means of diagnosis, so far as the urine is 
concerned. Fortunately these, if combined with a careful consideration of 
the clinical symptoms, are usually quite sufficient. 

Symptoms referred to the circulatory system are usually the first to 
be observed. Among these symptoms the oedema is the most prominent 
and distinctive. Some slight swelling of the feet is common enough in the 
latter months of pregnancy, especially in multiparse. It is especially 
noticeable when the patient has been on her feet during the day and is often 
associated with varicose veins. When, however, it is at all noticeable, or 
when it occurs in a primipara, or if it is present when the patient arises in 
the morning, it is to be regarded with suspicion. It is a safe rule to regard 
every case of oedema of the feet as a possible toxaemia and to institute a 
careful urinalysis. When the swelling extends up the leg and there is pit- 
ting on pressure over the tibia, marked evidences of toxaemia will usually 
be found. CEdema of the upper part of the body, and particularly of the 
hands or face, is a dangerous symptom. Puffiness under the eyes is highly 
significant, as is also swelling of the hands. Now and then the patient will 
complain that she has trouble in getting her rings on or off. Marked 
oedema of the labia and general oedema are evidences of profound 
toxaemia. 

A pulse of high tension and a blood pressure of 140 or more are highly 
suggestive symptoms if present, but I have not found their presence as 
uniform as is commonly supposed. 



GENERAL DISORDERS OF THE MOTHER 257 

Symptoms Referred to the Nervous System. — Among these, head- 
ache is especially prominent. It is often described as being located above 
and behind the eyes, ^^llen continuous and severe, it is of bad omen, 
perhaps portending an eclamptic attack. Other symptoms are nervousness, 
irritability, insomnia, twitching, vertigo, and ocular disturbances. The 
latter are of special significance. The patient may complain of trouble in 
reading or sewing, or of specks, or bright spots, before the eyes, or even 
that she cannot see at all. 

Symptoms Referred to the Digestive System. — These symptoms are 
usually less prominent, but should on no account be forgotten. Nausea 
and vomiting are so common in early pregnancy as to attract little attention 
unless excessive. Occurring in the latter months, however, they are often 
toxic in origin. The same thing is true of unusual or obstinate constipa- 
tion. Any kind of epigastric or abdominal pain not connected with uterine 
contractions, is to be regarded with suspicion. The cause of this pain is 
not clear. It may be most intense, reminding one of the gastric crises of 
locomotor ataxia. I recall a case in which epigastric pain so severe as to 
require a full dose of morphine hypodermatically, for its relief, was the 
immediate forerunner of an eclamptic attack. After the patient's recovery 
she had no more recollection of the pain and of the hypodermatic injection 
than of the convulsions which followed. 

In neglected or untreated cases and, very rarely, in spite of treatment, 
things go on from bad to worse. The amount of albumen increases, and 
epithelial and granular casts appear in abundance. CEdema of the face, 
shown especially by puffiness under the eyes, may be present. Severe and 
persistent headache is common at this time, and the patient may partially 
or even completely lose her vision. Vomiting and epigastric pain are 
characteristic. Contraction of the pupils is an ominous sign. 

These phenomena, or a majority of them, taken together, constitute the 
preeclamptic syndrome of the older writers. The picture is seldom 
seen nowadays, at all events, by those who practise modern methods. 

Such in brief are the symptoms of preeclamptic toxaemia. With these 
symptoms the practitioner should become familiar early in his career. And 
he should never forget to seek for them even though the patient makes no 
complaint. Not all these symptoms are present in every case, nor are they 
always pronounced ; but to wait until the chnical picture is unmistakable, 
before instituting treatment, may be to wait too long. 

What are the etiology and essential nature of this so-called toxaemia 
of pregnancy? Many theories have been advanced. Not one has been 
generally accepted. It is assumed that the condition is a toxaemia, but the 
nature of the toxin or toxins is not generally understood. The condition 
is the forerunner of eclampsia, and the etiology of the two will be 
considered together. 

Diagnosis. — This is usually easy. Alost mistakes are due to careless- 
ness rather than to lack of skill. The examiner should catalogue the svmp- 
17 



258 PATHOLOGY OF PREGNANCY AND LABOR 

toms in his mind, and go over them one by one. Occasionally one meets 
hysterical amblyopia in pregnant women, and oedema may be due to vari- 
cose veins, but in either case the urinalysis will settle the question. 
Albuminuria may be due to a vaginal discharge, but if the urine is drawn 
with the catheter and filtered all doubt is removed. 

It is more difficult to differentiate the condition from nephritis, since 
in the latter there may be both oedema and albuminuria. Nephritis, how- 
ever, occurring at this time, is usually the continuation of a process ante- 
dating pregnancy, and the symptoms are marked during the early months ; 
while preeclamptic toxaemia is distinctively an affection of the latter half 
of pregnancy, usually of the last two or three months, and often occurs in 
strong and vigorous young women, who have no history of nephritis or 
other serious illness. L^rsemic dyspnoea may be marked in nephritis, while 
the dyspnoea of toxaemia is subjective in character, and is hardly noticed, 
even by the patient herself. 

Of course, an acute nephritis may occur during the latter part of preg- 
nancy, but this is certainly very rare. In the absence of any history it 
might be impossible to distinguish the coma or convulsions of uraemia 
from those of eclampsia. 

The urinary findings may be of service. In preeclamptic toxaemia the 
quantity of urine is usually diminished, while this is not necessarily the 
case in nephritis. In the latter condition all kinds of casts may be found, 
whereas in toxaemia there are few casts except in severe cases verging on 
eclampsia. Finally in nephritis we do not have the high ammonia 
coefficient that characterizes preeclamptic toxaemia. 

Treatment. — The first manifestations of toxemia should be the signal 
for the institution of treatment. The earlier treatment is begun, the better 
the chances of success. I am accustomed to summarize the various steps 
of the treatment as follows : rest, diet, medication, hydrotherapeusis, fresh 
air, and oxygen. 

A patient showing symptoms of toxaemia should be put to bed. This is 
the first, and often the most important, part of the treatment. A post- 
scarlatinal albuminuria in a child is always regarded with apprehension, 
and made the subject of careful treatment. And yet, how often one finds 
a pregnant woman with albuminuria and swollen ankles doing her own 
housework, and burdened with all kinds of domestic cares. 

It is perfectly plain that when nature is trying to rid the system of 
some poison, she can accomplish her work better if other demands upon 
her resources are minimized. Moreover, this theoretical conclusion is 
confirmed by clinical experience. It is a matter of every-day experience 
that these patients usually improve rapidly if kept in bed for a time. If 
the patient cannot or will not do this she should be advised to refrain from 
work and worry as far as possible, to retire early, and to lie down for two 
or three hours every day. 

The patient should be put upon a milk diet. Milk is a sufficient nutri- 



GENERAL DISORDERS OF THE MOTHER 259 

ment and at the same time an excellent diuretic. Other articles of diet, 
especially red meats, shoiild.he proscribed, but it is not necessary to become 
fanatical upon this subject. An occasional cracker, or a stalk of celery, 
serves to encourage the patient, promotes the flow of saliva, and does no 
harm. Patients are sometimes sickened and disgusted by an exclusive milk 
diet, and it is therefore wise to vary the taste and composition of the milk 
as much as possible, after the manner of the French physicians. Thus it 
may be given, sometimes hot, sometimes cold, again diluted with water, 
lime water, or vichy, or flavored with some innocent aromatic, etc. The 
patient should be instructed to drink large quantities of water, or, if she 
prefers, of some alkaline mineral water. This diet should be continued 
until there is a decided improvement, and the resumption of the usual diet 
should be gradual and provisional. Some care should be observed in this 
respect during the remainder of her pregnancy. 

In many cases rest in bed and a milk diet would doubtless be sufficient ; 
but there are other methods of proved efficiency, and caution dictates their 
employment in every instance. 

Elimination. — Saline cathartics should be administered in quantity 
sufficient to produce one or two watery movements a day, for several days, 
For this purpose Epsom or Rochelle salts may be used. For susceptible 
patients the citrate of magnesia is sufficient and has the advantage of 
palatability. Among the diuretics Basham's mixture enjoys a good reputa- 
tion and the iron which it contains is useful, since these patients soon 
become anaemic. In urgent cases with considerable oedema, the infusion 
of digitalis, or diuretin, is to be preferred. Pilocarpine, sometimes advised 
for the purpose of furthering excretion by the skin, is dangerous and has 
been known to cause pulmonary oedema and death. The hot pack answers 
the same purpose. 

Elimination by the skin should be encouraged. A daily sponge bath is 
advisable, and if the symptoms are threatening the hot pack often brings 
improvement. 'Xot to be forgotten at this time is free colonic irrigation 
with hot salt solution, usually, but for no reason, reserved until the 
outbreak of convulsions. 

Let me anticipate for a moment the question of etiology. 

A'arious observers have endeavored to find the toxin in some imper- 
fectly oxidized body, e.g., lactic acid, but these efforts have been barren of 
results. So many skilled observers in all parts of the world have been 
working in this field that it seems difficult to believe that any specific poison 
could have escaped observation. 

]\Iay it not be that we have been looking too far for the cause of the 
symptom-complex, which we call the toxaemia of pregnancy, but which 
should be called the preeclamptic condition? In other words, may not 
suboxidation itself be the real cause, or, at all events, a prominent factor? 
In pregnancy a woman needs oxygen more than at any other time. The 
clinical symptoms, from the subjective dyspnoea, so common in pregnancy 



260 PATHOLOGY OF PREGNANCY AND LABOR 

approximately normal, to the headache, oedema, and final convulsions of 
profound toxaemia, are strongly suggestive of lack of oxygen. This theory 
helps to explain why eclampsia occurs so often in robust and vigorous 
young women. These patients have a high oxidative equilibrium and are 
the first to suffer from oxygen deficiency. 

Acting upon this theory, I have for more than two years treated all my 
toxsemic cases by the free use of oxygen inhalations in addition to the usual 
treatment. All these cases have done well, and none of them have gone on 
to the development of convulsions. Most of them have been hospital cases, 
and I have been able to watch them carefully and to supervise the details of 
the treatment. Many of them were well-marked cases, and several suffered 
from profound toxaemia. 

It is a w^ell-known fact that pregnant women are badly affected by the 
air of crowded places, and ill-ventilated rooms, and every observant physi- 
cian has noted the relief afforded by fresh air and the open window. There 
is a valuable lesson here. Many patients cannot procure oxygen, but there 
are few indeed who cannot get fresh air. In the treatment of toxaemia, 
and, for that matter, in all cases of pregnancy, careful attention should be 
paid to ventilation. An abundance of fresh air, both by day and night, is an 
important element in the treatment, and when the weather permits it is 
wise for the patient to recline upon a couch or hammock out of doors. I 
am convinced that what I have ventured to call the fresh air treatment of 
pregnancy in general, and of toxaemia in particular, will some day be 
generally recognized as is now the fresh air treatment of tuberculosis. 

With the exception of the oxygen, and the fresh air treatment, the 
measures here described are not new ; but they are none the less effectual. 
As a rule bad results are not due to the inadequacy of the treatment, but 
to the fact that it is applied too late. There are fezv conditions in which 
the resources of medicine are better exemplified than in the prompt and 
thorough treatment of preeclamptic toxccmia. 

In the few cases in which treatment is not successful, in which the 
albumen increases, and the total amount of urine diminishes, it is best to 
induce labor. True, there are cases which in spite of unfavorable symp- 
toms terminate favorably, but such cases are exceptional, and such a 
termination cannot be predicted. 

It is a consolation to remember that in these cases the child is usually 
viable and that the induction of labor is not always to its disadvantage. It 
has been abundantly demonstrated that the toxaemia injures the foetus as 
well as the mother. 

Puerperal Eclampsia 

The term eclampsia from the Greek kyldtx-tto, to flash, really means 
a convulsion and nothing more, but it has come to be applied to a condition 
characterized by convulsions and coma, and preceded by the symptoms of 
preeclamptic toxaemia already described. It is, indeed, the natural 



GENERAL DISORDERS OF THE MOTHER 261 

culmination of this toxaemia when untreated, or unaffected by treatment. 
The name is purely empirical and tells nothing of the essential nature of 
the condition, but aptly indicates the sudden nature of the attack. 
Eclampsia does, indeed, come like a flash to him who is unprepared. 

Etiology. — It seems clear that the causes of preeclamptic toxaemia and 
of eclampsia are the same. When the causal agent in toxaemia, whatever it 
may be, is allowed free play, when its pernicious activity is not arrested 
either by treatment or by the efforts of nature, the result is eclampsia. 
The immediate cause of the convulsions does not enter into the question — • 
at least not directly. Convulsions occur in many diseases of widely dif- 
ferent origin. The question to be answered here is, What is the cause of 
the condition which gives rise to the convulsions ? It is the fashion now to 
call the condition a toxaemia — to assume that it is a certain toxin circulating 
in the maternal blood that causes the symptoms of preeclamptic toxaemia, 
and eventually the coma and convulsions of eclampsia. But what is this 
toxin? This is still qiiestio vexata. Formerly it was thought to be 
uraemia, and the cause of the uraemia was thought to be a nephritis com- 
plicating pregnancy. The study of the pathology of the disease, however, 
which shows that the kidney changes are secondary rather than primary, 
and that the changes in the liver are more marked than those in the kidney, 
together with the diff'erences in the clinical history of the two conditions, 
has proved the falsity of this theory. It is astonishing, however, to see 
how strong a hold the idea still has upon the popular, and even the 
professional, mind. 

The theory of auto-intoxication first advanced by Bouchard was popular 
for a long time. According to this the cause of eclampsia is to be found in 
the inability of the kidneys to perform their task in the elimination of the 
excess of waste matter that must be disposed of during pregnancy. This 
he sought to prove by showing that the urine and blood serum of eclamptics, 
injected into animals, are more poisonous than normal urine and blood 
serum. Various observers disprove this theory by showing that the toxic 
properties of these fluids are due to their concentration, and that, when 
diluted up to the normal stand-point, they have no toxic action. 

The auto-intoxication theory, in one form or another, has always been 
popular in France, and Fabre and others now hold strongly to the belief 
that the absorption of decomposition products from the intestinal tract is 
the real cause of eclampsia. 

The modern " biological " theories and hypotheses have recently been 
much invoked in efforts to discover the cause of eclampsia, and of these 
theories Veit has been the most prominent exponent. It is well known 
that during pregnancy the blood is invaded by certain fetal elements, e.g., 
the syncytial elements of the placenta, which but for the development of a 
hypothetical antibody would do harm if present in excess, and that in 
eclampsia this antibody is not present. Somewhat analogous theories have 
been advanced by Ascoli, Weichardt, and Hofbauer, and contradicted by 



262 PATHOLOGY OF PRBCmANCY AND LABOR 

Frank, Heimann, and Lichtenstein. It is plain, even to the uninitiated, 
that these theories rest upon unverified assumptions. 

Schmorl and Dienst, noting the frequency of muUiple thromboses in 
eclampsia, ascribed their presence to the invasion of the blood current by 
an excess of fibrin ferment. Dienst went a step further and attempted to 
explain why the fibrin ferment is increased. There is, he says, an anti- 
thrombin which should normally neutralize any excess of coagulating 
material. This antithrombin is produced in the liver, but during pregnancy 
this organ may become unequal to the task. 

Thyroid insuf^ciency has been held by Lange, Nicholson, and others to 
be the cause, but no very positive evidence to this effect seems to have been 
supplied. It is probable that if thyroid extract does good in these cases it 
must be by its well-known effect in stimulating general metabolism and 
indirectly oxidation. 

Eclampsia has also been attributed to bacterial infection, but the offend- 
ing organism has not yet been found. Certain writers, of whom Sellheim 
was the first, have believed it to be due to the action of some toxin of 
mammary origin, and it has recently been suggested that it is an anaphy- 
lactic phenomenon. Many other theories have been advanced and for the 
most part quickly discarded. To discuss them all here would carry us far 
beyond our limits. 

On the whole it seems plain that the cause must be bound up with the 
presence in ntew of the living and growing foetus. The foetus may die as 
the result of the eclamptic poison or poisons, but seldom or never does a 
mother carrying a dead foetus develop eclampsia. Moreover, it is plain 
that the foetus must have reached an advanced stage of development, since 
eclampsia is essentially a disease of the latter months of pregnancy. 

Perhaps the most significant and encouraging studies that have recently 
been made have been those of Zweifel, Williams, Stone, Ewing and others, 
in connection with nitrogenous metabolism in pregnancy ; studies that have 
shown conclusively that during pregnancy large quantities of nitrogenous 
substances are excreted by the kidneys in a state of incomplete oxidation. 
It is assumed that this incomplete oxidation must be the result of some 
toxin of unknown origin circulating in the maternal blood and interfering 
with the oxidative function in the liver, or the eliminatlve work of the 
kidneys, or both. 

It seems to me that while the main facts in the above premises are true, 
the conclusion does not necessarily follow. Why need we assume the 
existence of some special toxin? May it not be that suboxidation itself is 
the real cause, or at all events a prominent factor ? In pregnancy a woman 
needs oxygen more than at any other time. Without this excess supply she 
cannot hope to meet the relatively enormous demands of fetal and placental 
metabolism. Moreover, in the latter part of pregnancy her oxygen supply 
is limited, owing to the diminished abdominal space and the consequently 
limited excursions of the diaphragm. This is, of course, especially true in 



GENERAL DISORDERS OF THE MOTHER 263 

cases of extreme distention, e.g., in hydramnion and in twin pregnancy, and 
it has long been a matter of common knowledge that both these conditions 
predispose to eclampsia. 

Zweifel has suggested that lactic acid, which has been found in the 
blood and cerebrospinal fluid of eclamptics by himself and his pupils, may 
prove to be a cause. To my mind it is a result rather than a cause. It is 
found in the urine of those who die of asphyxia. It is a symptom of 
suboxidation. The recent researches of Thomas Lewis show that in 
dyspnoea following exertion lactic acid is present in the blood as a result 
of the increase of its carbon dioxide content. 

The clinical symptoms of the toxaemia of pregnancy, from the subjective 
dyspnoea so common in pregnancy approximately normal, to the headache, 
oedema and final convulsions, are strongly suggestive of lack of oxygen. 
Xo other hypothesis helps to explain the seemingly inexplicable but un- 
doubted fact that eclampsia usually occurs in robust and vigorous young 
women. These patients, as before stated, have a high oxidative equilibrium 
and are the first to suft'er from oxygen deficiency. 

Pathology. — The pathological changes are most marked in the liver. 
Indeed, it is not too much to say that these are the only definite and char- 
acteristic changes. Schmorl, who has made the pathology of eclampsia his 
special field, declares that the diagnosis can be positively made out by the 
hepatic changes. Scattered throughout the organ are found areas of 
anaemic and hemorrhagic necrosis resulting apparently from thrombosis of 
the smaller portal vessels. According to Williams the necrotic processes 
in the eclamptic liver are to be sharply differentiated from those of the 
vomiting of pregnancy by the fact that they result from the extension of a 
thrombotic process and involve chiefly the periphery of the lobules, while 
in the vomiting of pregnancy the necrosis begins in the centre of the lobules. 

Some kidney changes are almost always to be found, but they are very 
variable. Their chief characteristic is, as Bumm aptly phrases it, that they 
are degenerative rather than inflammatory. In some cases, very few in 
number, there is little or no demonstrable change ; in others there is simply 
congestion, while in what is perhaps the majority of cases there are cloudy 
swelling and fatty degeneration of the epithelium. These changes are 
likely to be mistaken by superficial observers for true parenchymatous 
nephritis, but careful study shows that in eclampsia the changes are sec- 
ondary, rather than primary, and this is in harmony with the clinical 
history of the condition. 

Multiple thrombosis is the principal feature of the cerebral changes. 
Occasionally the vessel may rupture, with resulting apoplexy and eventual 
softening. Sometimes the brain is congested, at other times pale, auc-emic 
and oedematous. Doubtless these varying appearances correspond to 
different stages of the condition. A patient may die, for example, during 
a convulsion or at the height of an attack, with high temperature and 



264 PATHOLOGY OF PREGNANCY AND LABOR 

cerebral congestion ; more commonly, however, after gradual failure of 
cardiac action, with weak and irregular pulse and pulmonary oedema. 

Period of Pregnancy. — Like the toxaemia of pregnancy, eclampsia is 
essentially a disease of the latter months of the child-bearing process, in- 
cluding in this term labor and the puerperium. It has been noted in the 
sixth and seventh months of pregnancy, but this is uncommon. About 
half the cases occur during labor, though doubtless this labor is in many 
cases premature, having been brought on by the profound toxaemia. 
Perhaps one-half of the remaining cases are observed during the eighth 
and ninth months of pregnancy, before the beginning of labor, and the 
other half during the postpartum period. Cases reported as occurring dur- 
ing the first half of pregnancy are probably to be regarded as cases of 
nephritis, a different clinical and pathological entity. 

Frequency. — This has been variously estimated. Perhaps one in five 
hundred would be approximately correct in cases seen outside of hospitals. 
In hospitals it is considerably more common, doubtless because eclamptics 
are brought to the hospital for treatment. It is more common in primi- 
parae, and its greater frequency in twin pregnancy is well established. It 
is said to be more common in cases of hydramnion, but this, I believe, is 
doubtful. ]\Iany observers have claimed that it is more common in cold 
climates and in damp weather. Judging from the reports of many of my 
students at the Xew York Polyclinic, it is more common in remote and 
sparsely settled regions than in cities or suburban localities. I have more 
than once been surprised at the practical familiarity of these men with 
the condition, due, no doubt, as one of them explained, to the fact that 
they are seldom called until the patient is in labor and therefore have no 
opportunities for instituting prophylactic treatment. In Xew York I often 
meet general practitioners of considerable experience who have never seen 
a case. 

Clinical History and Diagnosis. — The usual if not the constant pro- 
dromata are those which we have already discussed as the symptoms of the 
preeclamptic condition. The most characteristic are severe and constant 
headache, visual disturbances, oedema of the face, and pain in the epigas- 
trium. The latter symptom occurring in a toxaemic case is highly signifi- 
cant and is often follow^ed in a few hours by the outbreak of convulsions. 

^^^illiams and others believe that, in rare instances, eclampsia may 
develop without prodromata of any kind, even without albuminuria. There 
seems to have been no room for error in his cases since they were under 
constant observation in a hospital. While not denying the possibility of 
such an occurrence I believe it to be extremely rare, as no such case has 
fallen under my observation. Pinard, in an enormous experience, saw 
but one case. 

Clinical History. — Its onset is dramatic and terrifying. The patient, 
who has perhaps just been conversing intelligently with her physician or 
nurse, is suddenly seized with a convulsion. If the physician happens to 



GENERAL DISORDERS OF THE MOTHER 265 

be watching his patient, the first thing noticed is that the eyes become fixed 
in an uncanny and unmeaning stare not pleasant to look upon. Then 
comes slight twitching of the face and eyelids, followed by spasm of the 
facial muscles and those of the upper part of the body, rolling of the eyes, 
and protrusion of the tongue. 

Now the scene changes. The second stage of the convulsion begins. 
The entire muscular system becomes fixed in immovable contractures. The 
thorax becomes immobilized, the breathing is arrested, the face is blue and 
cyanotic, to the uninitiated death seems at hand. Fortunately this stage, 
which seems endless to the onlooker, really lasts but ten or fifteen seconds. 
It ends suddenly with a deep inspiration which ushers in the third stage. 
Tonic and clonic convulsions of the whole body now follow. As a rule, 
however, the upper part of the body is most afifected. In some cases the 
movements are so rapid and violent that the patient can hardly be kept in 
bed. The breathing is irregular and stertorous, the pupils widely dilated, 
and from the parted lips issues foam, and blood from the bitten tongue. 
The temperature may reach 102° or 103° during the convulsions. In mild 
cases it falls after the convulsion is over. In severe cases it remains high 
during the intervals, in bad cases 103° or 104°. 

The cause of the high temperature in eclampsia has been the subject 
of controversy, having been variously regarded as toxic, thermal, or septic 
in origin. I am inclined to regard it as thermal since it occurs in many 
cases in which the clinical and bacteriological evidences of sepsis are 
absent, and in which there have been no internal manipulations. Of 
course, sepsis may occur in eclamptic cases, as in other cases. Some writers 
believe, indeed, that eclampsia predisposes, but I have not been able to 
convince myself that it occurs oftener than in other cases, if we allow for 
the fact that operative interference is so often practised. 

The pulse is rapid and of high tension, but strong and regular, and often 
reaches 130 or 140. It is best studied after the convulsion is over, for dur- 
ing the convulsion it is often intermittent, feeble, or even imperceptible. 
Doubtless this is due to the compression of the vessels by spasmodic 
muscular contraction. Any one who will carefully study a typical 
eclamptic convulsion will easily recognize the three stages which I have 
described. The stage of invasion, the stage of contracture, and the stage 
of convulsions. The division, of course, is that of the French writers, who 
have studied the clinical phenomena of eclampsia with unrivalled accuracy 
and precision. 

In mild cases the patient regains consciousness soon after the convul- 
sion, but remembers nothing of what has transpired. In severe cases she 
passes into a condition of profound coma as the convulsions recur. The 
entire convulsion does not usually last more than one minute, though, of 
course, it seems longer. As the first convulsion subsides the patient will 
be found in a semicomatose condition, and may not fully regain con- 
sciousness until some hours later, when she will be quite unaware that 



266 PATHOLOGY OF PREGNANCY AND LABOR 

anything unusual has transpired. In the more severe cases she passes into 
a condition of profound coma and Hes like one in an apoplectic stupor. 
The breathing- is stertorous, the pupils, which during the convulsion were 
widely dilated, have become contracted, and the pulse is again strong, 
regular, rapid, and of high tension. At intervals the convulsions recur ; 
though in some cases there may be but one or two. This is especially apt 
to be the- case in the postpartum variety. As many as one hundred or 
more have been reported. The intervals may vary from a few minutes 
to a few hours. 

The catheter brings but a few drachms, or even a few drops, of urine 
which becomes solid upon boiling. 

In a case of moderate gravity there may be ten or fifteen convulsions, 
the patient emerging gradually from her comatose condition, and the urine 
increasing in quantity, the pulse meanwhile remaining regular and strong, 
though still rapid. In the severe types the coma becomes profound, the 
temperature remains high, and jaundice is often marked. Alost significant 
of all, the pulse becomes weak and irregular and there is beginning pul- 
monary oedema. As a rule, death is not long in following. Sometimes the 
pulse is compressible from the beginning, a most unfavorable symptom. 

Mental disturbance following eclampsia is not uncommon. 

Prognosis. — Eclampsia is always a serious condition. The maternal 
mortality is from 20 to 30 per cent., and the fetal mortality, 50 per cent, 
or more. Postpartum cases are, in my experience, much less fatal than 
those that occur before or during labor. Cases in which the cervix is 
dilated or easily dilatable ofifer a more favorable prognosis than those, for- 
tunately rare, in which the cervix is rigid, and the canal persists in its entire 
length. Such cases, for example, as one meets occasionally in primipar?e 
in the fifth and sixth month. These cases are unfavorable because the 
attendant is obliged to choose between leaving his patient undelivered and 
adding the shock of a difficult operation to the burden which she already 
lias to bear. Thus we see that the earlier the attack occurs the greater 
the danger. 

In- my experience the most significant index of prognosis is the pulse. 
Profound coma and repeated convulsions are, of course, unfavorable, but 
they are by no means hopeless. If the pulse remains strong and regular, 
even though it be 130 or 140, as it often is, and of high tension, there is a 
fair chance for recovery. When the pulse becomes weak and irregular 
the prognosis is very bad. Sometimes the pulse is soft and compressible 
from the start, a most unfavorable symptom. Alarked jaundice and a per- 
sistent high temperature are bad signs. According to Polak a normal or 
subnormal leucocyte count is a fatal prognostic, while a high count if per- 
sistent is favorable. Complete anuria is, of course, one of the worst 
symptoms, whereas a gradual increase in the amount of urine is most 
encouraging. 

Diagnosis. — There can hardly be difficulty in the diagnosis of 



GENERAL DISORDERS OF THE MOTHER 267 

eclampsia. In my experience the malady which is most likely to simulate 
eclampsia is hysteria. According to my observation this occurs most often 
in illegitimate pregnancy. I can recall three cases, all in hospital practice, 
in which hysterical coma in advanced pregnancy presented a picture some- 
what like that of eclampsia. These patients may even have convulsions, 
though in this country hysterical convulsions are rare. Here we depend 
upon the results of urinalysis, since it is a well-known fact that hysterical 
women secrete large quantities of clear urine of low specific gravity. 

Ur?emic poisoning may be mistaken for eclamptic coma and the differ- 
entiation may be for the time impossible unless an accurate clinical history 
can be secured. Such a history would show evidence of a preceding 
nephritis, e.g., dyspnoea, oedema, and albuminuria, in early pregnancy or 
before pregnancy began. 

Eclampsia has been confused with strychnine poisoning, and epilepsy, 
but in both cases the history and the results of urinalysis should be suffi- 
cient. The remarkable resemblance of eclampsia to acute yellow atrophy 
of the liver, and of phosphorus poisoning to both, is discussed in connection 
with acute yellow atrophy. 

Finally acute bichloride poisoning from intra-uterine injection of 
bichloride solutions has now and then been diagnosed as eclampsia. 

Preventive Treatment. — The preventive treatment is by all odds the 
most important. It is far easier to prevent eclampsia than to cure it. If 
the practitioner will regard every case as one of possible toxaemia, watching 
carefully for the first danger signal, and treating it promptly by the 
methods already described, he will seldom be called upon to undertake the 
solution of this, the most difficult problem in obstetrics. Doubtless he will, 
in this way, give himself much unnecessary trouble, but he will be repaid 
in the end, if only by the satisfaction of a clear conscience. Let me appeal 
also to a lower motive. The general public has already learned that to 
omit urinalysis during pregnancy is to do grave injustice to the patient. 
It will not do to become careless because many cases do well though 
utterly neglected. Such an attitude is sure sooner or later to give ground 
for bitter remorse. Nor is it safe to presume upon the fact that one's 
patient is apparently strong and vigorous; for it is in just this class of 
cases that the dread disease oftenest develops. 

Another caution — it is the height of folly to wait for the appearance of 
symptoms that attract the serious attention of the patient and lead her to 
consult her physician. What some women will endure without complaint 
is often a matter of wonder to the medical adviser. Moreover, some of 
the most ominous symptoms of toxaemia, e.g., oedema of the face, suppres- 
sion of urine, are neither painful, nor particularly troublesome. The 
physician should see his patient every week or two during the latter 
months of pregnancy and satisfy himself as to her condition by ocular 
inspection and by judicious questioning as well as by urinalysis. 

Treatment. — It seems to me that reason and experience combine to 



268 PATHOLOGY OF PREGNANCY AND LABOR 

show that the chances of the eclamptic patient are improved by the empty- 
ing of the uterus, provided this can be done without profound shock or 
grave injury. This removes the foetus and placenta, which are at once the 
source, or in some way the cause, of the toxaemia, and by their presence 
the reflex excitant of convulsions. I am strengthened in my belief by the 
fact that postpartum eclampsia runs a much milder course than eclampsia 
that begins before or during labor. An incidental benefit, perhaps, is the 
loss of blood that accompanies the process of delivery. 

I therefore advise that if the physician finds his patient in labor 
he hasten the process as much as is consistent with the interests of the 
mother. For example, if she has reached the second stage the forceps 
should be applied and delivery accomplished. If she is still in the first stage,, 
and if the cervical canal is obliterated and the cervix easily dilatable or 
perhaps partly dilated, manual dilatation should be employed and deliver}^ 
accomplished by version or forceps, according to indications. In spite of 
his anxiety the operator should work carefully and deliberately, and in 
particular should he strive to avoid bad tears of the cervix and lower 
uterine segment by observing the rules laid down in the section on obstetric 
surgery. Bad tears of this kind, caused by an insane desire to complete 
delivery in a few moments at any cost, have sometimes been responsible 
for mournful results. 

Whenever delivery per znas naturales is contemplated it is well to 
begin by rupturing the membranes. This procedure, by reducing the 
abdominal tension, diminishes reflex irritation, undoubtedly a factor in 
causing the convulsions, and perhaps allows a better pelvic circulation, 
thus favoring elimination. 

The anaesthetic used should be ether oxygen and the admixture of 
oxygen should be plentiful. It has been clearly shown by various European 
investigators, and by Cragin and Hull in our own country, that chloroform 
produces lesions of the liver and kidneys similar to those in preeclamptic 
toxaemia and eclampsia. I have long believed that the free use of 
chloroform in eclampsia increases the tendency to death. 

Even if labor has not begun, if the patient is near term, it may be 
possible to pass a finger through the cervix and introduce a A'oorhees bag, 
going on with the induction of labor according to the rules already given, 
and the short delay involved is far better than an immediate resort to some 
heroic procedure. 

But suppose that the cervix is found quite unprepared for parturition, 
long and hard, the canal preserved in its entire length, the patient in all 
probability some months from term. Such a case cannot be safely treated 
by manual dilatation. Even dilatation with bags is here a long and tedious 
procedure, requiring repeated anaesthesias and manipulations, and perhaps 
not successful in the end. The situation is a serious one. What is to 
be done? 

If the patient can be transported to a well-equipped hospital and placed 



GENERAL DISORDERS OF THE MOTHER 269 

in the hands of a thoroughly competent operator the best resuUs will 
probably be secured by delivery by means of the vaginal or abdominal 
Caesarean section, according to the circumstances of the case. If the 
patient is a multipara and the child not over-large, the vaginal operation is 
the operation of choice, but if she be a primipara with a narrow vagina and 
perhaps a large foetus, the abdominal operation is, in my opinion, much 
to be preferred. 

On the other hand, if the operator is inexperienced or the surroundings 
unfavorable, it is better to rupture the membranes and treat the case 
medically by the methods which will be presently described. The rupture 
of the membranes is in itself a measure of relief, and labor usually follows 
within a day or two. Meanwhile it may be possible to control the con- 
vulsions by appropriate treatment. 

Cases, however, in which the necessity for this choice may arise are 
very rare. Eclampsia usually develops during the latter weeks of preg- 
nancy and the examiner almost always finds obliteration of the cervical 
canal and beginning dilatation of the external os. It is to be feared that 
those whose experience has been limited to surgery or pure gynaecology 
have now and then been led to perform the Caesarean section upon 
insufficient indications. 

I have discussed the obstetrical treatment of eclampsia first, because it 
is usually the most important, but the medical treatment is not to be for- 
g-otten. In some cases, e.g., in the postpartum cases, and in the cases in 
which, for some good reason, delivery cannot at once be undertaken, it is 
our only resource ; and in all cases it forms if not the principal part of the 
treatment at least a very important part of it. 

As is usually the case in most conditions, the etiology of which is not 
known, many remedial measures have been tried and discarded. It would 
serve no useful purpose to recount them all. 

There are three indications which it is well to bear in mind : 

1. The suppression of the convulsions and the promotion of muscular 
relaxation. 

2. The promotion of elimination. 

3. The reduction of the blood pressure. 

It is, of course, perfectly true that the convulsions do not in them- 
selves constitute the disease which we call eclampsia, but no one who has 
watched these convulsions can doubt that they are in themselves a source of 
danger. It was formerly the custom to treat the convulsions by the inter- 
mittent administration of chloroform continued over long periods. This is 
now generally recognized to be bad practice. As already noted ether 
oxygen is safer in these cases. But it is highly undesirable that the patient 
should receive more of any anaesthetic than is absolutely necessary. For 
the purpose of suppressing the convulsions ether should be used only as a 
temporary measure and should be supplanted as soon as possible by some 
other agent. Of these agents the best in my opinion is morphine hypo- 



270 PATHOLOGY OF PREGNANCY AND LABOR 

dermatically. It should be administered early in the attack while the 
patient still has a strong and regular pulse, and before the access of pro- 
found coma. With threatening heart failure, as shown by a weak and 
irregular pulse, and perhaps by beginning pulmonary oedema, it is, of 
course, a dangerous drug, and would only hasten the fatal end ; but this 
does not speak against its rational employment. 

I am in the habit of beginning with ^4 S^- to j/z gr., repeating the 
smaller dose, according to circumstances, sufficiently often to keep the 
patient in a quiet sleep for some hours. Personally morphine has seemed 
to me to do good and many of my students at the New York Polyclinic 
from all parts of the country, who have taken up this method on their own 
initiative, and without text-book or other encouragement, as the best 
method of suppressing the convulsions, report favorably. The use of 
morphia has been decried upon theoretical considerations as tending to 
lock up the secretions, but this is purely theoretical. When one sees a 
patient sleeping quietly and bathed in a profuse perspiration one need not 
worry about theories of the eliminative action of drugs. A'eit believes 
that it does good by producing muscular relaxation. I have often thought 
that it may act by modifying. or preventing the tremendous shock to the 
nervous system from the profound toxaemia and the resulting convulsions. 

Chloral hydrate enjoys a good repute among many competent observers. 
Clinical work, especially in France and Russia, seems to show that it does 
not have the deleterious effects of chloroform and recent experimental 
work by Hopkins leads to the same conclusion. It may be given per 
rectum in milk in doses of thirty or forty grains, repeated as necessary. 
Fochier has shown that the drug is tolerated by eclamptics in large doses. 

Veratrum viride has been lauded by many observers and that it brings 
about at least a symptomatic improvement cannot be doubted. It is given 
hypodermatically, in doses of five or ten minims, repeated every hour or two 
until the pulse falls to sixty. The drug not only shows the pulse but 
reduces the blood pressure, and its advocates claim that when the pulse is 
kept at sixty convulsions cannot occur. Polak and others claim that its 
efficiency is increased by combining it with morphine. 

Notwithstanding the favorable reports that have followed the use of 
chloral and veratrum viride, and without denying that they may form 
useful adjuncts in many cases, I have not been able to overcome my 
reluctance to the routine employment of cardiac depressants in eclampsia. 
I still prefer morphine used with discretion and judgment. To my mind 
it is a highly significant fact that both those who use chloral and those who 
use veratrum use morphine also, believing that in this way better results 
are procured. 

I have already referred to the use of oxygen in the toxaemia of preg- 
nancy. I believe it is indicated in all cases and I always use it when it 
can be obtained. Aside from all theories as to the real cause of the 
toxaemia and of eclampsia, there is no question that it is symptomatically 



GENERAL DISORDERS OF THE MOTHER 271 

indicated. This is clearly shown by the cyanosis and respiratory obstruc- 
tion. Therefore, its use can be productive only of good, no matter what 
the cause of the condition may be. 

If one adopts the suboxidation theory then the inhalation of oxygen is 
doubly indicated. It should be used freely and preferably by subcutaneous 
injection. It is injected under the breasts in ample quantity and absorbed 
with great rapidity. I have many times observed its good effect. 

When the blood pressure is high it may be reduced by nitroglycerin in 
1/50 gr. doses, or amyl nitrite by inhalation, and these remedies have, of 
course, no depressing eflect upon the heart. 

Eliminative Treatment. — Elimination by the bowels, kidneys, and skin 
should be encouraged. A drop or two of croton oil, or 54 gi"- elaterium 
upon the tongue, satisfies the first indication, and in this condition does not 
seem to be attended by the shock which it usually causes. Later, if neces- 
sary, a solution of Epsom salts may be given. After this the bowels may 
be kept open by Epsom salts, given, if necessary, through the stomach 
tube. Sweating may be induced by hot packs or by covering the patient 
with blankets and surrounding her by hot bottles. Pilocarpine is 
unnecessary and dangerous. 

Diuresis is favored by frequent and copious irrigations of the colon 
with hot salt solution. In my experience this is a valuable method of 
treatment. 

Venesection may also be regarded as an eliminative measure, since some 
of the toxins contained in the maternal circulation are thus removed. 
In my opinion this measure is only suited to patients of plethoric habit, 
w4th full and bounding pulse, and when immediate delivery is not con- 
templated. In these cases a single full bleeding is often of benefit. When 
immediate delivery is contemplated venesection should not be done. The 
patient may lose enough blood during the delivery and there is a limit to 
the amount of blood which even an eclamptic may safely lose. In post- 
partum cases, however, venesection is one of our most valuable measures. 

The intravenous injection of salt solution not only has a diuretic 
action, but serves tO' diminish the concentration of toxins circulating in 
the maternal blood. For the man unaccustomed to hospital technic the 
injection of salt solution under the breasts offers a convenient and efficient 
substitute. 

Zweifel, who holds the view that eclampsia is due to the presence of 
lactic acid and other intermediate acid products of nitrogenous metabolism, 
advises the intravenous injection of sodium bicarbonate. I believe that 
alkalies are beneficial in this condition, and that this fact is further con- 
firmation of the suboxidation theory, since acidosis is a common 
accompaniment of suboxidation. 

Thyroid extract has been used with reported good effect by Nicholson, 
and parathyroid by Vassale. It seems reasonable to suppose that whatever 
good effect may result from either of these preparations is due to the 



272 PATHOLOGY OF PREGNANCY AND LABOR 

stimulating effect of the thyroid secretion on oxidation and general 
metabolism. 

Sellheim, conceiving the idea that eclampsia is the result of some poison 
elaborated in the breasts, injected them with oxygen with a view to block- 
ing the circulation, and even went so far in one or two cases as to amputate 
the breasts. It is to be hoped that the latter procedure will not be imitated. 
In our own country Healy and Kastle, of the Kentucky Agricultural 
Experiment Station, acting upon the same hypothesis, have made a remark- 
able series of experiments in connection with the so-called parturient 
paresis of cattle, which bears a remarkable and pathological resemblance 
to eclampsia. Believing the disease to be of mam nary origin, they report 
a remarkable series of cures by the injection of the udders with oxygen. 
This would seem to afford striking confirmation of my own theory of the 
etiology of toxaemia and eclampsia, which I have briefly given in the 
preceding chapter. 

Renal decapsulation as advocated by Edebohls has not found favor in 
this condition. The theoretical considerations advanced in its favor are 
not sufficient to outweigh the risk of the operation. 

Kronig and, following him, several others have resorted to lumbar 
puncture, but the results have been indecisive. 

Engelmann has used hirudin, or leech-extract, intravenously with the 
idea of preventing coagulation of the blood, and thus preventing the forma- 
tion of the multiple thrombi which are so prominent a feature in the 
pathology of eclampsia. The remedy is still on trial. 

Summary of Treatment. — The young and inexperienced practitioner, 
called suddenly to a case of eclampsia, is apt to be confused by the sudden 
and alarming character of the situation and by the multitude of varying 
expedients and remedies that have been recommended in different quarters. 
He may console himself, however, with the reflection that the means that 
are of real value are few, and usually not difficult of application. 

While it is true that the obstetrical treatment is usually the most 
important, one should not forget the employment of other curative meas- 
ures. The necessary preparations for delivery, and the various steps of its 
performance, may require several hours, and in some cases it may be 
unwise to attempt immediate delivery. Meanwhile one should not be idle. 
If there are no contra-indications % gr. to ^ gr. of morphine should be 
injected and repeated as necessary. Anaesthetics are for the most part 
unnecessary and dangerous. They should be reserved for operative 
delivery. The membranes should be ruptured. Oxygen should be pro- 
cured if possible and given freely, especially during the convulsions. A 
folded towel should be placed like a bridle between the patient's jaws to 
prevent injury to the tongue. A drop or two of croton oil should be placed 
upon the tongue and the colon freely irrigated with hot salt solution. The 
patient should be covered with blankets and surrounded by bottles, not too 
hot, until free perspiration is induced. 



GENER.\L DISORDERS OF THE MOTHER 273 

The attendant should then make a careful examination and consider 
attentively the probable difficulties of delivery and especially the condition 
of the cervix. He should also consider his own experience and skill, 
remembering that in some hands the remedy may be worse than the disease. 
This applies to pure obstetrics as well as to surgery and surgical 
gyn^ecolog}'. For example, experience has taught me that manual dilata- 
tion and high forceps or difficult version are, in the hands of a surgeon 
or gynaecologist not well versed in obstetrical technic, quite as dangerous to 
an eclamptic patient as is the Csesarean section in the hands of a fairly well 
equipped general practitioner. 

Personally, I believe that the shock of an operative delivery is much 
increased by the outbreak of eclampsia. In toxaemia it does not seem to 
be attended by the same amount of shock. Moreover, the longer an attack 
of eclampsia is allowed to continue, and the more profound the coma 
becomes, the more easily is the patient affected by any surgical interference. 
Therefore, once the operator has made up his mind that delivery is in- 
dicated, and that he knows how to accomplish it, the sooner it is performed 
the better. The advice so often given, that before proceeding to operative 
delivery one should wait until all other measures have failed, is in the 
highest degree illogical. Operative delivery soon after the first convulsion 
carries a far better prognosis than the same measure performed as a last 
resort. 

During convalescence perfect quiet should be enforced, the patient 
should remain quietly in bed for a week or more and a diet, chiefly milk, 
should be continued. A cracker, or a little bread and butter occasionally 
to relieve the monotony, will do no harm. She should be encouraged to 
drink large quantities of water. Iron in one form or another is indicated 
to help make up for the loss of albumen and to counteract the anaemia 
which is always present. Fresh air is of the greatest importance. The 
patient's room should be well ventilated and time spent in the open air, e.g., 
reclining in an easy chair or upon a couch is well spent. Only when her 
condition has perceptibly and distinctly improved and the albumen has 
disappeared from the urine should she be permitted gradually to resume 
her usual diet and later her accustomed habits of life. 

In the postpartum cases there is, of course, no purely obstetrical treat- 
ment, but the medical treatment as outlined above should be carefully 
followed out. If the indications for venesection are present it is especially 
useful in these cases. 

The Vomiting of Pregnancy 

The so-called '' morning sickness " of early pregnancy is so common 
that it is hardly to be regarded as abnormal. Indeed, it is one of the most 
reliable of the presumptive signs of pregnancy. Sometimes, however, the 
condition becomes exaggerated. The nausea and vomiting are not limited 
to the morning hours, but continue throughout the day and night. Not 
18 



274 PATHOLOGY OF PREGNANCY AND LABOR 

only is food rejected, but vomiting may continue when the stomach is 
empty. The condition may become so exaggerated as to impair the general 
nutrition of the patient or even to threaten her life. The morning 
sickness has become the " vomiting of pregnancy." 

Here again, as in the case of eclampsia, we are obliged to use a term 
that is purely empirical. A'omiting, of course, is only a symptom, not a 
disease. In this case it is the chief symptom of a condition the essential 
nature of which we do not as yet understand. 

Etiology and Classification.— The underlying cause of the vomiting of 
pregnancy is not known. The most plausible hypothesis advanced is that 
of toxaemia, but no serious attempt has been made to explain the nature of 
the supposed toxin or toxins. Stone, Ewing, and others, believe that the 
vomiting of pregnancy, preeclamptic toxaemia, eclampsia, and acute yellow 
atroph}- of the liver are all results of one and the same cause, acting under 
different conditions and at different periods of pregnancy. This has not 
as yet been proven. It has been shown, however, that they all have certain 
things in common. For example, they are all accompanied by profound 
changes in nitrogenous metabolism and in the oxidative functions of the 
liver. To me it is most suggestive that oxygen has been found useful in 
the vomiting of pregnancy. There are still, however, many clinical and 
pathological differences to be explained, and many apparent contradictions 
to be reconciled, before this theory can be accepted. 

There is no doubt whatever that the condition is more common in 
neurotic and hysterical subjects and in patients of neurotic heredity. Some 
women have a better appetite and digestion during pregnancy than at any 
other time. 

Whitridge Williams, who has made exhaustive studies in this field, 
recognizes three varieties of vomiting: neurotic, toxsemic, and reflex. He 
admits, however, in the latest edition of his work, that his belief in reflex 
causes of vomiting is rapidly diminishing. Personally I agree with him 
and with Kaltenbach, Bumm, and others that the alleged cures in these 
cases are, for the most part, the result of the procedures employed for the 
relief of the supposed causes, such procedures acting by suggestion. I 
regard this as clearly proven by the fact that Copeman's method of simple 
dilatation of the cervix with the finger unquestionably produces good 
results in many cases. Moreover, certain conditions often regarded as 
reflex causes, e.g., constipation, really act by increasing the toxaemia. 

In spite of all this, however, it must be admitted that the existence of a 
reflex cause is possible during pregnancy, as at other times, and it should be 
carefully sought for in every case which does not respond to treatment. 
Among alleged reflex causes are tumors, displacements, erosions of the 
cervix, etc. 

Most cases then are either neurotic or toxaemic. It is quite likely that 
toxaemia is the underlying cause in many of the cases that are put down 
as neurotic. Some writers, indeed, believe that toxaemia is the ultimate 



GENER.\L DISORDERS OF THE MOTHER 275 

cause of all kinds of vomiting, even including the usual morning sickness. 
This, however, is probably an exaggeration since some women vomit almost 
from the moment of conception and it can hardly be claimed that toxaemia 
begins with the beginning of pregnancy. 

Pathology. — It appears that in the vomiting of pregnancy, as in 
eclampsia, the brunt of the burden falls upon the liver. According to 
^^'illiams the process differs from that of eclampsia, consisting in necrosis 
beginning in the centre of the lobules, or in general fatty degeneration of 
the organ : whereas in eclampsia it is the result of thrombosis, and begins 
in the periportal spaces. As in eclampsia, however, the kidney changes 
are degenerative rather than inflammatory and are only marked in severe 
cases and in those approaching a fatal termination. 

On the whole the lesions are much the same as in acute yellow atrophy 
of the liver. 

AMlliams believes that the difference in the pathology is so marked 
that the cause of toxaemic vomiting must be essentially different from that 
of preeclamptic toxaemia. This the future will determine. 

Clinical History. — The condition is emphatically one of early preg- 
nancy. It usually begins in the second month, though it may begin earlier. 
As the months pass its appearance becomes less probable. When, how- 
ever, it begins early in pregnancy it may continue until the patient is 
delivered at or near term, as I have myself witnessed. 

Xausea and vomiting occurring after the fifth or sixth month of 
pregnancy often indicate preeclamptic toxaemia; less often nephritis or 
some other intercurrent or complicating disease. 

The symptoms of the neurotic type, or of the mild or benign type, as it 
is often called, are simply those of the ordinary morning sickness some- 
what exaggerated. Instead of being confined to the early morning they 
continue with more or less persistence during the day and night. The 
patient vomits much of what is taken into the stomach, but by no means 
all, and sometimes less than is supposed. She is nervous and depressed. 
Constipation is the rule. The face is pallid and the patient obviously 
more or less anaemic. The pulse remains normal, however, and the loss 
of flesh is not marked. Urinary changes are slight or absent. 

TOXEMIC VOMITING 

The clinical history of this condition has been well studied in France, 
where the condition seems much more common than in Germany, England, 
or America. The older writers styled this pernicious vomiting. This 
designation, though colloquial rather than scientific, is certainly very 
appropriate and expressive. Its beginning is usually the same as that of 
the neurotic type, but the symptoms do not respond to treatment, and the 
case goes on from bad to worse. The first distinctive evidence of the 
toxaemic or severe type is rapid loss of flesh. This symptom, indeed, is 
the chief characteristic of the first stage. 



276 PATHOLOGY OF PREGNANCY AND LABOR 

Dubois, who has written upon this subject with singular accuracy and 
clearness, recognizes three stages : 

The first period, or period of emaciation ; the second period, or period 
of rapid pulse ; the third period, or period of cerebral symptoms. 

First Period 

After a varying period of what is regarded as the neurotic or benign 
type of vomiting the symptoms gradually become more severe. The patient 
now vomits not only after taking food but also when no food has been 
taken. The loss of flesh now becomes quite perceptible, and from this 
time on is rapid. The constipation, which is a constant accompaniment 
of even the milder forms, becomes more obstinate, and the urine 
diminishes in quantity. Ptyalism is common. 

Second Period 

During this period emaciation continues and albumen appears in the 
urine, but the most characteristic symptom is the increased rapidity of the 
pulse, which may vary from loo to 120. Jaundice and tenderness over the 
liver are ominous symptoms pointing to grave toxaemia. There is no fever, 
but on the other hand the temperature may be subnormal. The vomited 
matter becomes black from admixture of blood. Gingivitis is common. 

Third Period 

This is the terminal stage and was characterized by Dubois as the 
period of cerebral symptoms. The urine is dark in color and almost com- 
plete suppression may ensue. Jaundice may become marked and the skin 
very dark in color. Delirium and coma precede the fatal termination. 

In this country, at least, the stages are not always so clearly marked, 
nor are the symptoms so definite or characteristic. The third stage is 
seldom seen, perhaps because patients are not allowed to reach this stage. 

In certain cases, fortunately very rare, toxsemic vomiting runs an acute 
and very rapid course, ending fatally in two or three weeks. 

Diagnosis. — The symptoms of the vomiting of pregnancy are usually 
unmistakable, though one should not forget the possibility of ulcer of the 
stomach. It should be remembered that, as noted above, nausea and vomit- 
ing occurring during the latter months are more commonly an evidence of 
preeclamptic toxaemia. Persistent vomiting may precede a convulsion. 

By far the most important point with reference to the diagnosis is the 
distinction between the benign and the pernicious forms, or, to use the 
current phraseology, between the neurotic and toxsemic types. 

This is, indeed, of the highest importance and may determine the final 
result, for the methods of treatment of the two types are diametrically 
opposed. 

In the severe type the patient vomits, not only after taking food, but 



GENERAL DISORDERS OF THE MOTHER 277 

also when the stomach is empty. The pulse is often, though not always, 
continuously rapid. Emaciation is progressive. Slight jaundice and 
tenderness over the liver may appear. These signs should always be 
carefully weighed. To wait for the phenomena of the third stage is to 
wait too long. 

]\Iost important is the evidence afforded by urinalysis. According to 
Soudern and others acidosis is an early symptom of toxaemia. Albuminuria 
and a diminution in the total quantity of urine are danger signals. 

According to A\'illiams the urine of toxsemic cases shows a high' 
ammonia coefficient, 20 to 50 per cent., as opposed to the normal coefficient, 
which is 4 or 5 per cent. In other words, the amount of nitrogen eliminated 
as ammonia is proportionately very large. The urea and total nitrogen 
are diminished. This sign may afford valuable corroborative evidence, but 
its recognition requires the services of an expert analytical chemist. More- 
over, since it may be present in the terminal stages of any exhausting dis- 
ease, or in acidosis from any cause, it is of negative rather than positive 
value. For example, if the ammonia coefficient is 5 per cent, or less, the 
vomiting is not tox^emic in character and even when the coefficient is high 
this may be due to inanition from any cause, or to other conditions which 
seriously interfere with metabolism. Nevertheless, if further experience 
shall confirm these conclusions it will prove of great value in deciding the 
question of the induction of abortion. 

In the majority of cases then the practitioner will still be obliged to 
fall back upon the clinical evidences already discussed. 

The duration of the neurotic cases varies from a few weeks to several 
months, and in some cases even to the end of pregnancy. The duration 
of the toxsemic cases averages two or three months. In certain cases, for- 
tunately rare, the toxaemic variety runs a very rapid course, ending fatally 
in a week or two. 

A single word of caution. The physician should not take it for granted 
that the vomiting of pregnancy is impossible in unmarried women. I recall 
a case in which the patient was supposed to be suffering from ulcer of the 
stomach. She was unmarried and no suspicion of the real condition 
was entertained. Every case of persistent vomiting in a woman of child- 
bearing age should be made the subject of careful investigation. 

Prognosis. — There is a mysterious and unaccountable difference in the 
figures given by different observers. The French, unquestionably acute 
observers, and with more material at their command than others, report 
a mortality of 30 per cent, in the severe type. In Germany the mortality 
is much lower, while Carl Braun, of Vienna, in an enormous experience, 
has never seen a fatal case. Part of this difference, but certainly not all, 
may be accounted for by the fact that the induction of abortion is resorted 
to earlier in Vienna and in Germany than in France. 

In the neurotic type the prognosis is good. With proper treatment the 
cure is neither difficult nor delayed. This is also true of the rare cases in 



278 PATHOLOGY OF PREGNANCY AND LABOR 

which the trouble can be traced to some reflex cause. In the true toxsemic 
cases the prognosis is always grave, especially if the condition is allowed 
to continue. It must be, however, that this form is for some reason more 
common in certain countries and localities. I am sure that cases of death 
from the vomiting of pregnancy are rare in New York and vicinity. 

Treatment. — ^lore interesting to the practitioner than all these theo- 
retical considerations, fascinating as they are, is the question of treatment. 

It is well to clear the ground at the outset by a systematic search, ex- 
ternal and internal, for the reflex causes of vomiting. Personally, I am 
of the opinion that most of them are imaginary, but that they do occasion- 
ally occur, is unquestionable. Moreover, such an examination, especially if 
the patient be allowed to regard it as a curative measure, often works 
wonders by suggestion. 

Of course if any abnormality is discovered it should be corrected. 
Operable tumors should be removed, displacements corrected, ulcerations 
cauterized, etc. 

I believe that Kaltenbach's conception of the vomiting of pregnancy as 
a neurosis marked an important advance in the treatment of this condition, 
and am free to confess that I had little success until I began to treat it 
upon this basis. The number of remedies that has been suggested is 
legion. Among them may be mentioned creosote, calomel, iodine, bismuth, 
cerium oxalate, pepsin, ingluvin, opium in one form or another, the 
bromides, chloral, and various others. In my opinion the best of these are 
those which have a sedative or hypnotic action. The aerated waters are 
always refreshing in nausea, and the old prescription of Fordyce Barker, 
a drachm of sodium bromide in a siphon of carbonated water, a draught 
to be taken every few hours, is often useful. Cocaine in doses of gr. ^ 
may give temporary relief ; or the pharynx and nares may be sprayed with 
a I or 2 per cent, solution, thus abolishing the sensation of swallowing. 
Morphine hypodermatically may bridge over a temporary emergency. 
Adrenalin, in doses of ten drops of a i to looo solution, by the mouth, 
twice daily has proved successful. Pepsin, hydrochloric acid, and similar 
agents are usually of little or no value, as might be expected, since the 
condition is ordinarily neurotic or toxic rather than gastric. In cases, 
however, in which the patient has been a dyspeptic before pregnancy, I 
have obtained good results from liquid taka-diastase in doses of one or 
two teaspoonfuls. 

These patients are usually constipated and for the relief of this condi- 
tion I have found cascara very useful. It should be given regularly for a 
time, the dose and the intervals between doses being adapted to the indi- 
vidual case. It may sometimes be advantageously combined with the 
tincture of nux vomica. Salines are to be avoided as tending to increase 
the anaemia already present. For the latter symptom some preparation 
of iron should be given. 

The French, who regard this condition as an auto-intoxication of in- 



GEXERAL DISORDERS OF THE MOTHER 279 

testinal origin, attach great importance to thorough flushing of the 
intestinal canal, and this measure is doubtless of some benefit. Williams 
reports great relief in some cases by washing out the stomach and leaving 
therein 500 c.c. of a i per cent, solution of sodium bicarbonate. It is a 
curious fact that here, as in preeclamptic toxaemia, relief may sometimes be 
obtained by the inhalation of oxygen. This, together with the benefit 
sometimes derived from the administration of alkalies, tends, I think, to 
confirm my belief, expressed elsewhere, as to the importance of combating 
suboxidation during pregnancy. It would also seem to indicate that there 
is some connection between the two conditions. 

Dietetic Treatment. — This is of less importance than one would sup- 
pose. If the patient vomits on rising or after breakfast, a cup of coffee or 
some preferred article of food should be taken while she is still in bed and in 
the recumbent position. As a rule acids are to be avoided and alkaline drinks 
like vichy or milk and lime water are to be advised. Patients who have 
been dyspeptics before becoming pregnant should, of course, avoid things 
that are known to disagree with them, but, on the other hand if a patient 
suffering from the vomiting of pregnancy expresses a desire for some 
unusual or apparently unsuitable article of food it may be advisable to 
allow it. Nature is sometimes the best teacher, and sometimes works by 
methods unknown to science. Rectal feeding, one egg in four ounces of 
pancreatized milk every few hours, or liquid peptonoids, may be tried for 
a few days, or even a week, but is not of as much value as was formerly 
supposed. 

Solid food may be retained when liquid food is rejected, and vice versa. 
Oftentimes solicitous friends give too much food at one time. A tea- 
spoonful may be retained when a teacupful is rejected. Sometimes it is 
taken better when hot, at other times when ice cold, and so on. A favorite 
expedient in the French hospitals is to give the soiipe de pain ciiit of 
Fochier. This consists of buttered toast made into a very thick soup with 
water and a little salt added. This is often retained by the stomach. The 
mere weight of the mass makes its rejection difficult. According to Fab re 
if it is once retained the case is cured. 

In rebellious cases of the neurotic type sanitarium treatment, or at all 
events a complete change of scene and surroundings, may effect a cure 
after all else has failed. 

Upon the hypothesis that the vomiting of pregnancy is due to the 
absence of certain antibodies that should be present in normal pregnancy, 
and that serve to counteract the injurious effects of the invasion of the 
circulation by fetal elements, various observers have recently treated the 
condition by the hypodermatic injection of serum taken from the blood 
of a pregnant woman near term. Reports seem to indicate that this 
procedure is worthy of further trial. Injections of salt solution, the tube 
being carried far up into the colon, are very valuable. The patient lies 
with the head low and the hips elevated and the solution is allowed to enter 



280 PATHOLOGY OF PREGNANCY AND LABOR 

drop by drop. In more urgent cases the subcutaneous injection of salt 
solution in liberal quantities should be practised. Both these measures 
are to be highly recommended. 

The physician should make his personality felt from the beginning. 
He should be confident and impart his confidence to the patient, li medi- 
cine is given or manipulation performed it should be done with the full 
assurance of cure. Keeping the patient in a darkened room and giving a 
little bromide in camphor water (Hirst) often suffices. An ice-bag over 
the epigastrium serves to diminish reflex irritability. 

In the toxaemic variety, as determined by progressive emaciation, con- 
stant rapidity of the pulse, persistent vomiting when the stomach is empty, 
and perhaps by a high ammonia coefficient, the induction of abortion must 
be seriously considered. These cases involve a serious responsibility and 
the advice of an experienced colleague should always be sought. 

In the induction of abortion ether or nitrous oxide should be employed, 
and with a liberal admixture of oxygen. In my opinion it is better to 
dilate the cervix carefully with the Hegar dilators, rupture the mem- 
branes, and tampon cervix and vagina. This can be done in a few moments 
and with practically no hemorrhage or shock. Strangely enough, the mere 
rupture of the membranes sometimes stops the vomiting at once. 

In the induction of abortion ether should be the anaesthetic, and it 
should be given with a liberal admixture of oxygen. If the cervix is 
dilated, or easily dilatable, it is well to complete the process at one sitting. 
On the other hand, if the cervix is rigid and undilatable and especially if 
the patient has passed the second month and the ovum has acquired 
considerable bulk, it is far better to dilate the cervix cautiously with the 
Hegar dilators until it will admit the tip of the finger, then rupture the 
membranes and tampon the cervix, lower uterine segment, and vagina. 
All this can be done in a few moments and with practically no hemorrhage 
or shock. The process completes itself or may be easily completed the 
next day. Strangely enough the mere rupture of the membranes some- 
times stops the vomiting at once. 

Acute Yellow Atrophy of the Liver 

It is a remarkable fact, and one hitherto unexplained, that pregnancy 
predisposes to acute yellow atrophy of the liver. ]\Iore than one-half of 
the reported cases have been observed in pregnant women. Indeed, it was 
called icterus gravis by the older writers. It is unnecessary to rehearse the 
pathology here. The liver changes are for the most part confined to the 
lobules, which undergo partial, or in bad cases almost complete, necrosis. 
With this process there goes an acute parenchymatous nephritis and fatty 
degeneration of the heart. The association reminds one of the pathological 
picture in toxaemic vomiting. 

Clinical History. — The symptoms may appear at any time during preg- 
nancy, or may follow labor by a few days. They are usually observed. 



GENERAL DISORDERS OF THE MOTHER 281 

however, during the latter months. The most distinctive symptom is 
jaundice, which may be shght or weh marked, and coma, which may 
develop slowly or gradually. In the acute cases the onset is sudden and 
severe, with headache, vomiting, purging, abdominal pain, and perhaps 
delirium and convulsions. The vomited matter may be blood stained, or 
of the coft'ee-ground variety, as in the last stages of the vomiting of 
pregnancy. Premature delivery of a dead foetus is common. 

Local Signs. — These are determined by palpation and percussion. 
Tenderness over the liver is marked, and diminution of the area of dulness 
rapid. 

L'rixary Findings. — The urine is much diminished in quantity and 
contains albumen, blood, bile, casts of all kinds, indican, and acetone. The 
amino-acids are increased. According to Williams the excretion of urea is 
much diminished while the ammonia coefficient is relatively very high. 

For the general practitioner without a^Jabor^tory -at- his- disposal- the- 
presence of bile, blood, and albumen should be sufficient. 

Diagnosis. — AMthout doubt the afifection has often been mistaken for 
eclampsia, and probably the differential diagnosis is not always possible. 
The data given above should be sufficient. It has been confounded with 
phosphorus poisoning, Avhich is also attended by fever, jaundice, convul- 
sions, coma, coffee-ground vomit, and oddly enough by the same or very 
similar pathological lesions. Here one would have to depend upon the 
history of the case, and upon the chemical examination of the vomitus, the 
dejections, and the urine. 

Prognosis. — This is bad. Few cases recover. 

Treatment. — The only treatment for this disease, a disease which is 
almost uniformly fatal, destroying mother and child alike, is the artificial 
interruption of pregnancy. If an anaesthetic is necessary, chloroform, 
which may still further damage the liver, should be avoided. The medical 
treatment is in a general way the same as that of preeclamptic toxaemia. 

Chorea Gravidarum 

Chorea, occurring as a complication of pregnancy, may assume a severe 
type. Often the constant movements make rest or sleep impossible, and 
exhaustion rapidly supervenes. The worst type is that which develops 
during pregnancy. When the disease was present before conception the 
symptoms are less severe. There seems to be a special relation between 
the disease and pregnancy. Fever, delirium, and coma are observed in the 
severe cases, the clinical picture reminding one of toxaemia. As in the 
vomiting of pregnancy, however, there seems to be a strong mixture of the 
neurotic element, and Wade reports a recovery by Copeman's method of 
cervical dilatation. 

The condition is always serious, the maternal mortality being as high 
as in eclampsia, i.e., 20 or 30 per cent. The occurrence of fever is a bad 



282 PATHOLOGY OF PRECiXAXXY AND LABOR 

prognostic sign. Abortion and premature labor are common. Many of 
the severe cases abort spontaneously. 

Treatment. — Arsenic, iron, cod liver oil, if well borne, and general 
hygienic measures are indicated. Possibly the serum treatment might be 
beneficial. Sedatives may be necessary to reduce motor excitement and 
secure sleep. Aggravated cases may require the induction of labor. 

Alany other affections of pregnancy are regarded as more or less toxic 
in origin. The term toxaemia is a sort of cloak that is conveniently used 
to cover many things that are as yet only " seen through a glass darkly.'' 
For example, neuroses, psychoses, dermatoses, and many other morbid 
conditions, are often attributed to toxaemia and doubtless are due in large 
part, or in many cases, to misunderstood perversions in metabolism re- 
sulting from the failure of the organism to meet the demands of pregnancy. 
Lentil, however, the whole matter is better understood, we will avoid con- 
fusion by considering them from a purely clinical stand-point. 



CHAPTER XIV 
INTERCURRENT AND COMPLICATING AFFECTIONS 

During pregnancy, as at other times, women are subject to the various 
diseases and disabihties to which the flesh is heir. It cannot be said, 
however, that they are more subject to them than their non-pregnant 
sisters. Indeed, it would seem that, in the case of some women at least, 
nature confers a sort of immunity from intercurrent affections. Then 
there are the fortunate patients who feel better during pregnancy than 
at any other time. Of this class we all see frequent examples. 

To consider every disease that might possibly occur during pregnancy 
would be an endless and profitless task. We will limit ourselves here 
to the more common affections, and to those which affect the course of 
pregnancy in some special manner, or are themselves modified in some 
special way by the fact that they occur during pregnancy. 

Let us take up first the chronic infectious diseases. Of these there 
are two which are of great interest and importance, syphilis and 
tuberculosis. 

Syphilis 

It is a well-known fact that syphilis is by far the most common cause 
of abortion, of premature labor, and of still birth. These sad results, 
however, occur chiefly in cases in which the patient contracts the disease 
before conception. In this event the child, even if delivered alive, is 
always syphilitic. This is true also, though to a less extent, of those cases 
in which the disease is transmitted at the time of conception or later. 

Strangely enough, however, in these so-called conceptional cases it is 
quite possible for a syphilitic father to beget a syphilitic child without, 
at the same time, infecting the mother. In this case the mother appears 
to acquire immunity from the disease, as shown by the fact that she does 
not contract it from the foetus. For example, she may with impunity nurse 
her child, even though it has specific lesions about the mouth. 

This merciful dispensation of nature is known as CoUes's law. Un- 
fortunately it is not of universal application. Now and then the mother, 
though not contracting the disease from the husband, may contract it 
indirectly from the child begotten by him ; the ciioc en retoiir of the French 
writers. 

Sometimes by a singular inversion of Colles's law the child of a 
syphilitic mother acquires immunity from the disease. For example, the 
child may nurse the mother with impunity even though the latter may 
have specific lesions of the nipple. This is known as the law of Profeta. 
It has recently been shown, however, that these children, though free from 
symptoms, give a positive Wassermann reaction. 

The discovery of Colles's law of immunity naturally led to the belief 

283 



284 PATHOLOGY OF PREGNANCY AND LABOR 

that the disease is transmitted through the spermatozoa. This has been 
disputed on the ground that the spirochseta palhda is much too large to be 
contained in the head of the spermatozoon, and on the further ground that 
these supposedly immune mothers give a positive Wassermann reaction. 
Those who hold this opinion assume the existence of what they call 
latent syphilis in the mother. To my mind clinical experience rather than 
laboratory results constitute the final test, and judged by this standard 
Colles's law still holds good. 

Granting, for the sake of argument, the truth of Colles's law, how is 
it to be explained? How is the immunity of the mother brought about? 
The best explanation seems to be that certain products of fetal metabolism 
are transmitted through the placenta to the mother and act as immunizing 
agents. Profeta's law is to be explained in the same way except that here 
the process is reversed, the immunizing products passing from the mother 
to the foetus. 

Clinical History. — The student is often left to assume that the course 
of syphilis during pregnancy is the same as in the non-pregnant condition. 
This is by no means correct. Syphilis modified by pregnancy has a 
symptomatology of its own. 

If the mother contracts the disease at the time of conception, or if 
conception occurs during the early period of the disease, the secondary 
symptoms, especially the anaemia and the headaches, are more severe than 
otherwise. In other words, the more recent the syphilis the more 
pronounced the symptoms. 

Owing to the increased blood supply of the genitals during pregnancy, 
the initial lesion is more prominent and tends to become phagedenic in 
character. If, however, the initial lesion occurs elsewdiere it is not modi- 
fied by the disease. Mucous patches are very obstinate, remaining for a- 
long time, and assuming a condylomatous appearance (Fabre). - 

If a pregnant woman is infected before the fifth month of her preg-; 
nancy the child will probably inherit the disease. If the infection dates- 
from a later period the child usually escapes. 

In this postconceptional syphilis, as it is called, the clinical course of 
the disease dififers somewhat from that already described. The secondary 
symptoms are not pronounced. The eruption is not well marked and the 
glandular enlargements rapidly disappear. According to Fabre mucous 
patches and pigmentations of the neck, the so-called Collar of Venus, 
are seen in only about five per cent, of the cases. The same writer calls 
attention to the value of headache, more severe at night, as a diagnostic- 
feature, its nocturnal character serving to distinguish it from the headache, 
of preeclamptic toxaemia. 

The disposition of the mother to abortions and premature labors, and 
the frequency of still-born children, are due to certain lesions of the. 
placenta and membranes, and secondarily of the foetus, which are peculiar 
to syphilis and which merit separate consideration. 



COMPLICATING AFFECTIONS 285 

The placental changes are in part apparent even to the naked eye. The 
placenta is much increased in size and much lighter in color. Pinard 
was wont to say that if the placental weight is more than one-sixth the 
weight of the foetus the case is one of syphilis. It has been shown, how- 
ever, that this rule, while suggestive and valuable, is subject to exceptions. 
In some cases the placenta is considerably heavier than is here indicated. 
Fabre reports a case in which the foetus weighed 1700 grammes and the 
placenta 1400 grammes. In the conceptional cases it may not be enlarged 
at all : not even relatively. The microscope reveals endarteritis, endo- 
phlebiti?. and cellular proliferation in the chorionic villi. These changes 




Prolifera- ^^ ^^^ 

tive ^ ^„ ^ '^ ^. \-^y_''s^ , ^^ • v''^' P^^H Moderately 

enda.rte- «|^ — -.«--«,„,.„^ _ .^-■-■~^- .^,^ — " "'^ ^ ' ", ' r' -^m/^M — thickened 

^^^B ^^^H layer 



Fig. 173. — Microphotograph of syphilitic artery. 

render the villi larger and give them the well-known club-shaped appear- 
ance characteristic of this condition. It is at once apparent that these 
changes are sufficient to account for the frequency of fetal disaster. The 
spirochsetae pallidse, while easy to find in the dead foetus, are rare in the 
placenta and many observers have failed to find them at all (Figs. 173, 
174 and 175). 

When the foetus dies in utero it soon becomes macerated (Fig. 176). 
The distinctive feature of maceration is the loosening and separation of 
the sklfi ffom the underlying tissues which are of a vivid red. Any hand- 
ling of the child, even the necessary manipulations, carefully conducted, 



286 



PATHOLOGY OF PREGNANCY AND LABOR 



results in further peeling off of the skin. The child is much below the 
usual size. The skull is soft and compressible and the abdomen is dis- 
tended. Without going deeply here into the subject of the pathology 



-''t^/^^^"^^c-r2^.V-^-^y^^3 




Fig. 174. — Villi from the line of demarcation between healthy and diseased placental tissue. 
(Frankel.) a, swollen villus filled with granulation cells; b, slender, almost healthy villus; c, transition 
from healthy to diseased villus. 




&MtmM' 



>3 




Fig. 175- — Syphilitic villus of the chorion. (Frankel.) 

of fetal syphilis it may be said that the principal well-established lesions 
consist in interstitial changes in the liver and spleen with marked enlarge- 
ment of those organs, in less marked but similar changes in the lungs, 
pancreas, testicles and elsewhere, and in the familiar osteochondritis of 



COMPLICATING AFFECTIONS 287 

the long bones. The spirochietcX are present in large numbers. One 
need not be a trained pathologist to secure strong presumptive evidence. 




Fig. 176. — Macerated foetus. 



According to Grafenburg, maceration is of specific origin in eighty per 
cent, of the cases and according to Whitridge Williams a marked increase 



288 PATHOLOGY OF PREGNANCY AND LABOR 

in the size and weight of the liver and spleen justifies the diagnosis of 
syphilis. The reader should remember that there are other causes. Syphilis 
is not the only cause of maceration. It is observed in mole pregnancy 
and may occur whenever a dead foetus remains long in utero. 

More important to the practitioner are those evidences of fetal syphilis 
that are visible to the eye. It is imperative that he be familiar with these, 
for if he fail to recognize them proper treatment will not be instituted, 
and much harm both to mother and child may result. 

The syphilitic child is much smaller than normal. The. subcutaneous 
fat seems to be absent or much diminished, the skin is folded and wrinkled, 
and the child looks prematurely old. A dingy gray color takes the place 
of the rosy hue of the healthy child. In some cases jaundice is present. 
The skin cracks open easily, especially at the flexures of the joints. 
Bull^ may be present upon the palms of the hands or the soles of the 
feet. This sign is highly characteristic. 

The Wassermann reaction may be negative, both as to the blood and 
the cerebrospinal fluid, less often with the latter. 

Even before delivery one may make a provisional diagnosis of syphilis 
in the foetus if, with a suggestive history, one finds evidences of maceration. 
These evidences are somewhat as follows : The abdomen ceases to enlarge. 
The fetal heart sounds disappear. The fundus is found at a lower level 
than that which should correspond to the existing period of pregnancy. 
According to Fabre one can predict the death of the foetus several days in 
advance by noting the gradual slowing of the heart sounds. The foetus is 
felt simply as a foreign body in utero. The back cannot be made out nor 
can the small and softened head be recognized. 

Hydramnion may be present and in some cases the distention may 
become excessive, even requiring the induction of labor. The distention 
develops gradually, in contrast to that of the hydramnion of twin preg- 
nancy, which may appear suddenly and increase rapidly. 

The gross changes in the placenta constitute a valuable means of 
diagnosis and the pathological conditions which cause these changes 
explain the fetal mortality. The accompanying endarteritis and endo- 
phlebitis by obliterating the vessels so interfere with the fetal and mater- 
nal interchange, that the death of the foetus often becomes inevitable. 

Treatment. — On the whole the treatment of syphilis during pregnancy 
does not differ materially from that ordinarily employed. The reader 
will do well to remember, however, that during pregnancy mercurials are 
not well tolerated by the stomach. For this reason inunctions are to be 
preferred. Extensive experience at the New York City Hospital has 
shown us that salvarsan can be employed during pregnancy without danger 
to mother or child. As in other conditions, it is especially valuable when 
the local lesions are marked. Treatment should be instituted early, when- 
ever possible, but it should never be omitted because the disease was 



COMPLICATING AFFECTIONS 289 

contracted late in pregnancy. Xor should it be omitted in cases of 
habitual abortion or of habitual premature death of the foetus, or when 
the husband is syphilitic, even though the mother shows no sign of the 
disease. In addition to the specific medication the general nutriment 
should be conserved in every possible way. A liberal diet and an abundant 
supply of fresh air are indispensable. 

Jeannin advises that, if the disease is not contracted until the patient 
is seven and one-half or eight months pregnant, labor be induced in order 
to prevent the development of syphilis in the child. It has been shown 
that in syphilis acquired during the latter months, i.e., in the late post- 
conceptional cases, the disease may not be transmitted to the foetus until 
the last month of pregnancy. 

The local lesions should be promptly and energetically treated, and 
if possible cured before the advent of labor, since their presence markedly 
increases the danger of infection. 

It should not be forgotten that patients suffering from syphilis are 
poor subjects for major surgery. I recall the case of a patient who died 
of infection after the Caesarean section during my interneship at the City 
Hospital. 

Xo man who has suffered from syphilis should be permitted to marry 
in less than four years from the beginning of the disease, and not then 
unless with the approval of a competent syphilologist and after every test, 
including of course the Wassermann reaction, has been employed. 

A syphilitic child may nurse its mother but should on no account be 
given to a healthy woman to nurse. DeLee has with justice emphasized 
the fact that it is absolutely unjustifiable to impose this risk upon a wet 
nurse. 

Tuberculosis 

It was formerly believed that pregnancy is, so to speak, an antidote 
to tuberculosis, that its occurrence in pregnancy is of good import. This 
belief was based upon the fact that there is, in many cases, a temporary 
improvement due to the gain in weight and general nutrition that so often 
marks the latter half of pregnancy. Abundant experience has shown, 
however, that tuberculosis, as a complication of pregnancy, is highly 
undesirable. Sooner or later its bad effects are manifest and often they 
develop with startling rapidity. This is especially true of the puerperal 
period. That an acute exacerbation is likely to occur at this time is 
proverbial. 

The symptoms of tuberculosis do not differ materially from those that 
accompany the disease in the non-pregnant condition. During the early 
months of gestation the anaemia and general malnutrition are usually 
pronounced, but in the latter months there is often considerable improve- 
ment. Too often, however, this is followed by a rapid decline after 
deliver}^ 
19 



290 PATHOLOGY OF PREGXAXCY AXD LABOR 

Strangely enough spontaneous abortion is rare in these cases. Prema- 
ture labor, however, is common, and is largely due to the mechanical 
effect of a violent and continued coughing. High temperature may also 
be a cause. 

In my experience the first stage of labor is not materially modified. 
The second stage, however, is often delayed, the patient being incapable 
of much voUmtar}^ muscular effort. The principal danger at this time 
is cardiac exhaustion with resulting pulmonary oedema. 

Whether the bacilli are transmitted to the foetus has been the subject 
of much discussion. Recent investigation tends to show that although 
this does undoubtedly occur it is exceptional, except perhaps in miliary 
tuberculosis. Clinical experience tends to confirm this view. AA> often 
see children born of tubercular mothers, who are and remain apparently 
in good health. Friedmann has shown that an infected spermatozoon may 
carry the bacilli to the ovum, and ^Mlliams considers that this fact may 
possibly account for those cases in which the disease does not appear until 
some time after birth. 

All this, however, does not mean that a patient in whom a slight tuber- 
cular process has been arrested, and who has remained for some years 
in good health, must under all circumstances remain childless. Every 
physician has seen cases in which such a patient has with good care sus- 
tained the ordeal of pregnancy and labor. Such cases should of course 
be carefully watched and their nutrition conserved in every possible way. 
If practicable they should lead an out-of-door life during the greater part 
of gestation. 

While some investigators have claimed that tuberculosis may be trans- 
mitted from mother to child, every-day experience shows that this is rare 
indeed. The modern theory is that a tubercular tendency may be trans- 
mitted. This, too, is open to question. 

Treatment. — The prophylactic treatment is most important since it 
offers most chance of success. The physician should never omit a complete 
general examination of his patient, including the heart and lungs, early in 
pregnancy; and this even if she thinks herself perfectly well. Every 
case of cough or of rapid loss of flesh should be investigated. In this 
way, and in this way only, will he discover the evidence of tuberculosis 
in its incipient stage, when with proper treatment there is still a fair chance 
of improvement. If he does not make such an examination he may now 
and then have occasion to regret its omission. If nothing wrong is found 
no harm has been done. The physician has only shown a proper interest 
in his patient ; an interest which is always appreciated. On the other hand, 
if incipient tuberculosis, cardiac disease, or nephritis is made out the 
information may be of priceless value. Of course urinalysis constitutes 
part of the examination. 

On the other hand, if the patient is in an advanced stage of the disease, 



COMPLICATING AFFECTIONS 291 

or if, even though the disease has made Httle progress, she is in the latter 
months of pregnancy, a waiting pohcy should be adopted. My experience 
has been that tubercular patients are poor subjects for anaesthesia and the 
operative procedures that are likely to form part of the induction of 
labor, and that such procedures, while prejudicing the chances of the child, 
do not benefit, but rather endanger, the mother. 

During labor the patient must be narrowly watched. A long delayed 
second stage may require the use of the forceps. The deep anaesthesia is 
undesirable, however. In one very serious case I disobeyed all rules and 
gave ergot, thus saving the patient an operative delivery. Pituitrin might 
be indicated here. If an anaesthetic must be given it should be adminis- 
tered in the smallest possible quantity and accompanied by liberal quanti- 
ties of oxygen. Special precautions should be taken to avoid any post- 
partum loss of blood. The mother should on no account nurse her child. 

Acute Infectious Diseases 

SCARLET fever 

Scarlet fever is, fortunately, of rare occurrence during pregnancy. 
Abortion or premature labor may occur, but are not as common as in 
measles. It is always a dangerous complication, since it imposes an addi- 
tional burden upon the kidneys, already taxed with the elimination of 
fetal and placental waste. 

]\Iany believe that pregnant women are immune to scarlet fever. It 
has seemed to me that this applies to other diseases as well. It appears 
that the disease is more common during the puerperium, though doubtless 
many of the cases reported have been cases of infection accompanied by an 
er}^thematous rash. 

Ballantyne, who studied the subject exhaustively, believed that the 
disease may be transmitted to the foetus, and reported a case in which the 
child was born with a rash which he believed to be that of scarlet fever. 

The immunity from scarlet fever, which pregnant women seem to 
enjoy, continues during the puerperium in which, according to Meyer, 
the disease does not occur in more than i per cent, of those known to 
have been exposed. It is a matter of common knowledge that puerperal 
patients occupying the same room with children suffering from scarlet 
fever seldom contract the disease. Of course this is no excuse for 
carelessness 

The chief interest of the physician centres in the fact that the diagnosis 
is very difficult, since erythematous rashes are not uncommon in cases of 
septic infection. As is well known, atypical cases of scarlet fever are quite 
common, and this materially increases the difficulty. Moreover, and this 
is not commonly known, a septic rash may desquamate. If the throat con- 
ditions are typical, and the urine contains albumen, the diagnosis is plain. 
A history of recent exposure also has some bearing, although not as much 



292 PATHOLOGY OF PREGNANCY AND LABOR 

as in the non-puerperal woman. In many cases the data are not sufficient 
for a positive diagnosis. In doubtful cases it is best to take all necessary- 
precautions in the way of isolation and disinfection. In this way the 
interests of the patient are best served and the attendant escapes the 
possibility of criticism. 

In my opinion many of the cases reported as scarlet fever were really 
cases of infection accompanied by erythemata. Since the introduction 
of the antiseptic system we have heard little of epidemics of scarlet fever 
as a complication of the puerperium. There is an old hospital tradition, 
probably founded upon fact, that scarlet fever is especially likely to be 
communicated to those having open wounds. It is very interesting to note 
in this connection that the streptococcus which recent investigations have 
shown to be the probable cause of scarlet fever is, as we know, the usual 
cause of septic infection in the puerperium. 

The child often escapes, even when the diagnosis in the case of the 
mother is undoubted. 

MEASLES 

This disease is also uncommon during pregnancy. When it does occur 
it is a serious matter. Bronchopneumonia as a complication is relatively 
frequent. Fellner reports abortion or premature labor in 55 per cent, 
of his thirty cases and a maternal mortality of 15 per cent. He empha- 
sizes the gravity of the affection when occurring in the puerperium. 
Numerous cases in which the disease was transmitted to the foetus have 
been reported. 

PNEUMONIA 

During the latter part of pregnancy pneumonia is an extremely dan- 
gerous, and often rapidly fatal, complication. Premature labor is the 
rule. The diminution of the oxygen supply, already scanty, is a factor 
most prejudicial to both mother and foetus. Strangely enough, the mor- 
tality is much higher when premature labor occurs than when it does 
not. Perhaps this is partly because it occurs more frequently in the severe 
cases. Then, too, the strain of labor upon the already overburdened heart 
must be a factor. At all events, the lesson is plain. The induction of 
labor is ordinarily contra-indicated. 

I have noted that in the case of a pregnant woman seriously ill with 
pneumonia, perhaps unconscious and with stertorous breathing, labor may 
begin and proceed far into the second stage without noticeable symptoms, 
and this, too, in the case of a primipara. Here the attendant may be 
surprised by finding the cervix completely dilated, when he had not even 
suspected the existence of labor. It is well to be on one's guard in these 
cases. 

INFLUENZA 

The reports vary markedly with different observers. My own obser- 
vation has been that the affection, as observed in New York and vicinity, 



COMPLICATING AFFECTIONS 293 

does not usually interrupt pregnancy or seriously imperil the life of the 
patient. In severe cases, however, with high fever or constant cough, 
premature labor is common. Should pneumonia develop the outlook 
is bad. Some cases, as is well known, are attended by great systemic 
depression, out of all proportion to the local symptoms. Here, if labor 
should occur, whether prematurely or at full term, the patient's resources 
should be carefully guarded and every effort made to forestall exhaustion 
and hcmorrliage. Chloroform anaesthesia should be avoided. 

MALARIAL FEVER 

As a complication of pregnancy and the puerperium malarial fever 
is certainly rare in New York and vicinity, though it is more common in 
other parts of our countr}^, notably in the Far South. In the severe cases, 
accompanied by chills and high temperature, pregnancy is often inter- 
rupted, especially in the latter weeks of pregnancy. 

It is generally believed that the disease may be transmitted to the 
foetus, but positive evidence seems to be lacking. Williams, in fifteen 
cases, failed to find the plasmodium in the blood of the child, though the 
blood was " carefully and repeatedly " examined in every case, and some 
of the children were born when the mother was suffering from a malarial 
attack. 

In malarial subjects the disease has a tendency to reappear during 
pregnancy and the puerperium, especially the latter. When occurring 
during the puerperium it bears a striking resemblance to pygemic infection, 
and without a blood examination the diagnosis may be for a time impos- 
sible. This subject is considered in the chapter on puerperal infection. 

There has been a tendency on the part of some observers to withhold 
quinine in these cases, fearing that its use might result in the interruption 
of pregnancy. This is a mistake. The danger of bringing on labor by the 
use of quinine is far less than that involved in the continuance of recurring 
chills and high temperature. This has been my own experience, and I 
have found it the unvarying testimony of physicians from the Far South 
studying at the New York Polyclinic. 

TYPHOID FEVER 

The coincidence of typhoid fever and pregnancy is rare. Pregnancy is 
said to be interrupted in more than one-half of the cases. Yet I have 
watched a patient in her progress through a typical attack of typhoid 
and a typical convalescence and seen her delivered without untoward 
incident. It was an unasual and uncanny task to trace the distended 
and tympanitic coils of intestine that lay above and in front of the uterus 
which extended far above the umbilicus. 

F. W. Lynch, of the Johns Hopkins clinic, has demonstrated the bacilli 



294 PATHOLOGY OF PREGNANCY AND LABOR 

in the organs of the aborted foetus. This helps to account for the frequency 
with which pregnancy is interrupted. 

Occurring in the puerperium, the disease may be confounded with 
sepsis, and the diagnosis may be difficuh for a time. The history will 
help and the subacute bronchitis, so familiar to those who have seen much 
of typhoid, is not characteristic of puerperal sepsis. The AMdal test should 
never be omitted. 

The attendant should not forget that wounds in the genital tract may 
be the seat of inoculation by the typhoid bacillus, a true puerperal infection 
resulting. 

ERYSIPELAS 

This is not very common in child-bearing women. Although this 
disease is a typical streptococcus infection, and would seem to be especially 
dangerous in pregnancy and the puerperium, experience does not show 
this to be the case. The transmission of the infection to the genitalia 
is possible, however, and may occur in two ways, either directly, e.g., 
by the hands of the patient, or indirectly through the blood current. Fatal 
cases have been reported. Pregnancy is not usually interrupted. Trans- 
mission to the foetus has been observed. 

Treatment. — The erysipelas should be cured as soon as possible. The 
best application in my experience is a 50 per cent, ichthyol ointment under 
oiled silk. The parts should be covered with sterile dressings and all 
handling of the genitalia scrupulously avoided. 

OTHER LOCAL INFECTIONS 

'Streptococcic inflammation of the throat, abscesses of various kinds, 
-etc., may complicate pregnancy and the puerperium, and may, in rare 
instances, cause an antepartum or postpartum infection in one or the 
other of the two ways mentioned above. 

ACUTE MILIARY TUBERCULOSIS 

This condition makes rapid progress during pregnancy and the diag- 
nosis is difficult. It is of special interest in this connection since it may be 
mistaken for an acute puerperal infection. 

The rarer acute infectious diseases, smallpox, cholera, typhus, are all 
serious complications of pregnancy and usually result in abortion. 

Of smallpox we see little in this country, but those who have had oppor- 
tunities for observation report the maternal mortality as high and the 
interruption of pregnancy as very common. Vinay reports 36 per cent, 
maternal mortality. The disease is often transmitted to the foetus in 
Mtero, as is said to have occurred in the case of the famous accoucheur, 
Mauriceau. Schutz reports that in the Hamburg cholera epidemic more 
than half the cases died and that abortion was very common. Occasional 
transmission of the disease to the mother was observed. 



COMPLICATING AFFECTIONS 295 

Diseases of the Circulatory System 
cardiac disease 

Happily women with cardiac disease sufficiently pronounced to cause 
grave anxiety are not likely to become pregnant. When pregnancy does 
occur, its premature interruption is common. This is ordinarily attributed 
to the fact that the uterine mucous membrane, like other mucous mem- 
branes, suffers from the venous stasis that is so often a part of the cardiac 
condition. One may form an idea of the condition of the membrane in 
these cases by observing the color of the lips in well-rnarked cyanosis. 
The same causes that produce the congestion may, of course, if sufficiently 
marked, result in hemorrhage, and this is sometimes observed. But there 
are other causes. The foetus may die as the result of lack of oxygen, 
either directly owing to maternal cyanosis, or indirectly as the result 
of placental apoplexies due to high blood-pressure. 

In my experience the unfavorable influence of pregnancy and labor 
upon cardiac disease has been much exaggerated. The mere fact that 
patients have a heart lesion does not usually make the prognosis unfavor- 
able, provided compensation is good. In some cases patients with organic 
heart lesions, sufficiently pronounced to cause grave anxiety, undergo the 
ordeal of pregnancy and labor without appreciable disadvantage. I recall 
a case of aortic disease with pronounced anginal attacks in which the 
diagnosis was made by the late Dr. E. G. Janeway. The patient passed 
through labor without special incident. Naturally one cannot rely upon 
such a fortunate termination. Aluch myocardial degeneration is of course 
unfavorable, hence mitral lesions, other things being equal, are more 
dangerous than aortic. The mere fact that a well-marked cardiac murmur 
is present is of little significance as long as the pulse is good and there 
are no evidences of lack of compensation. According to Fabre valvular 
lesions of rheumatic origin are the most dangerous of all. This corre- 
sponds with my own observation. 

The symptoms of cardiac disease in pregnancy are, in a general way, 
the same as in the non-pregnant condition. In cases of failing compen- 
sation in the latter part of pregnancy, distention and dyspnoea may be 
extreme. Albuminuria may be present and must be differentiated from 
the albuminuria of pregnancy. Embolism is more common than in the 
non-pregnant condition. Renal embolism with anuria has been noted, 
another condition which may simulate eclampsia. Flemiplegia, amaurosis 
and gangrene of the extremities have been observed. 

During labor the danger is greatest during the expulsive stage, the 
period immediately preceding delivery. During the expulsive stage it is 
due not only to the great muscular exertion and to the congestion attendant 
upon the bearing-down efforts, but also to the rise in blood-pressure. The 
occurrence of serious symptoms shortly after delivery is usually attributed 
to the diminution of intra-abdominal pressure. 

In fatal cases the patient may die suddenly and with little immediate 



296 PATHOLOGY OF PREGNANCY AND LABOR 

warning, or death may be preceded by an acute pulmonary oedema. The 
latter condition has been specially studied by Vinay. Its most character- 
istic symptom is a very copious and abundant expectoration — the expec- 
toration alhuynineuse of the French writers. This is accompanied by 
dyspnoea and cyanosis, and by an abundance of moist rales. 

Treatment. — The treatment of cardiac disease during pregnancy is 
both medical and obstetrical, and it is a great mistake to forget the medical 
treatment. If compensation is good, and there is no evidence of myocar- 
dial degeneration, active measures are not necessary, but the patient should 
be very carefully watched. The hygiene of pregnancy elsewhere described 
is to be carefully followed, and all kinds of mental and physical overstrain 
scrupulously avoided. Indigestion and constipation are especially to be 
feared in these cases and should be avoided as far as possible. Tepid 
baths and dry frictions are useful (Fabre). An abundance of fresh air 
is a sine qua non and oxygen inhalations are beneficial. The anaemia of 
early pregnancy should always be treated. The heart muscle is in need 
of the best blood that can be afforded. One should watch attentively for 
symptoms of failing compensation, and it is here even more important than 
in the non-pregnant condition, that such symptoms should be anticipated 
and treatment, e.g., the administration of digitalis, begun at the earliest 
possible moment with the idea of forestalling dangerous developments. 

If evidences of failing compensation appear in the early months the 
induction of abortion is to be considered, since under such circumstances 
it is highly unlikely that either mother or child will survive the prolon- 
gation of pregnancy, and the strain and probable accidents of labor. Ether 
oxygen, or nitrous oxide with oxygen, should be the anaesthetic, and an 
expert administrator should be secured if possible. The slower methods 
of procedure should be avoided. 

During the latter months, however, the induction of labor is a much 
more serious matter, extending over hours and involving all the gravity 
of a major operation. It is better, therefore, to try medical treatment 
first, and resort to extreme measures only if this fails. If dyspnoea and 
cyanosis are marked some relief may be obtained by the immediate 
puncture of the membranes. Labor is then allowed to develop spon- 
taneously. In cases of extreme urgency anterior vaginal hysterotomy is 
the operation of choice. 

Prophylaxis.^In view of the bad effects that may result from the 
combination of cardiac disease and pregnancy, some writers have advised 
that marriage be forbidden in all cases. This is perhaps going too far. 
The mere presence of a heart murmur often means little or nothing. 
If, however, other evidences exist, and especially if there are any indica- 
tions of decompensation, the dangers involved should be clearly explained 
to those most interested. 

Treatment During Labor. — During the first stage interference is not 
usually indicated. Everything possible should be done to conserve the 



COAIPLICATING AFFECTIONS 297 

strength of the patient. Excessive suffering may and should be mitigated 
by the use of morphine or pantopon. Suitable nourishment should not be 
forgotten. During the second stage expulsive eft'orts should be discour- 
aged and the patient most narrowly watched. It is usually advised that 
labor be completed by forceps as soon as the cervix is fully dilated, but 
the shock of anaesthesia and hemorrhage that accompany a rapid forceps 
operation, and perhaps above all the sudden diminution of the intra- 
abdominal pressure, are of themselves highly dangerous in these cases. 
It is needless to say that these dangers are greatly increased if the operation 
is not done lege artis. Personally I believe that this procedure should be 
reserved for those cases in which the second stage is unduly prolonged or 
obviously injurious to the patient, or in w^iich there is already evidence 
of decompensation. To operate simply because the patient has a heart 
murmur will, in the long run, do more harm than good. If, however, 
unfavorable symptoms, e.g., weakness or irregularity of the pulse, dyspnoea, 
etc., are observed, delivery cannot be delayed. 

How should delivery be accomplished ? Obviously by whatever method 
can be performed most quickly and with the least danger to the mother. 
If the head is in the vagina the forceps may be applied. If the conditions 
are favorable for an easy version, this operation should be performed. 
If the cer\'ix is undilated and rigid, anterior vaginal hysterotomy is the 
operation of choice. A few whiffs of ether oxygen should suffice for 
any of these operations. Cardiac cases should not be allowed to go beyond 
term. In this way prolonged and difficult deliveries are best avoided. 

To obviate the ill effects of the sudden diminution of the intra- 
abdominal pressure, I am in the habit of applying a snug abdominal 
binder as soon as the foetus is expelled, and without waiting for the 
expulsion of the placenta. 

The danger is not always over with the completion of labor. The 
patient should be carefully watched for some hours. I recall a case in 
which cardiac dilatation occurred suddenly several hours after delivery. 

For threatened or actual collapse camphor in oil, digalen and strophan- 
thin are perhaps the best stimulants. Richter advises the intravenous 
injection of strophanthin. In the presence of pulmonary oedema a prompt 
and full venesection may afford relief. If the membranes are still intact 
they should be ruptured at once, no matter what the stage of labor. 

Pituitrin, which markedly increases the blood-pressure, is contra-indi- 
cated in these cases. 

Varicose veins of the lower limbs may be a source of great suffering 
during pregnancy. More than this they constitute a positive danger, 
since in case of rupture serious and even fatal hemorrhage may ensue. 
They probably predispose to phlebitis, thrombosis and embolism. They 
are much more amenable to treatment than is usually supposed, and should 
always be treated. 

Every morning, before the patient arises, the leg, or, if necessarv. the 



298 PATHOLOGY OF PREGNANCY AND LABOR 

leg and thigh, should be carefully bandaged, from the roots of the toes 
upward. The bandage should always be Ccirried above the knee, and in 
the case of varices of the thigh it should be continued and held in position 
by means of a spica around the waist. It should be worn- during the day 
and should not be removed until the patient retires for the night. Such 
a bandage can hardly be properly applied by the patient lierself, but, in 
the absence of a trained nurse, any intelligent member of her family can 
be taught to do it for her. This simple treatment not only affords imme- 
diate relief but prevents the veins from becoming larger, a matter of 
considerable importance. 

The patient should avoid long standing. Many women stand when 
they might as well sit, merely from force of habit. They should be taught 
that many things can be done sitting. Nothing should be worn that tends 
to constrict the waist. Constipation should be treated by the methods 
already described, and if the patient must go about she should be provided 
with a pad and bandage and instructed in its use. To lie down for an 
hour or two during the day with the feet elevated upon a pillow affords 
great relief. 

Hemorrhoids, which of course are only varices of the rectum, may 
give much trouble in the latter months of pregnancy. Ice is on the whole 
the best local application. Anusol or opium suppositories may be used. 
An ointment of resorcin and oil of cade does much to allay external irri- 
tation. Much relief may be obtained by lying upon the back with the 
hips elevated upon a pillow, thus allowing the blood to gravitate away 
from the pelvic structures. Constipation should be treated by the methods 
already described. 

Varices of the vulva may attain enormous proportions. Haematomata 
may thus be favored, occurring for the most part during operative delivery. 
Lacerations, which fortunately are not common, probably for the reason 
that these patients are usually multiparse, may bleed severely. 

Probably rupture of some internal varix, e.g., of the broad ligament, 
may account for some mysterious cases of sudden death during pregnancy 
and labor which could not be diagnosed in vivo. DeLee has reported such 
cases. 

Embolism is rare in pregnancy. Varicose veins and cardiac disease 
are predisposing causes. It is more common in the puerperium, as we 
shall see later. 

Diseases of the Respiratory System 
Asthma is an occasional complication of pregnancy. It Is probably 
of neurotoxic origin, as it sometimes occurs in patients who never suffer 
from it at any other time. Those who are subject to asthmatic attacks 
suffer much more during pregnancy. Doubtless this is due in part to the 
deficient oxygen supply. Hirst has observed that complete change of air 
and scene constitutes the best treatment. 



COMPLICATING AFFECTIONS 299 

INIore common during- pregnancy is emphysema. Abortion is relatively 
common. Here again oxygen deficiency serves to make the condition less 
bearable. According to the same writer the administration of oxygen, 
bv counteracting the excess of carbon dioxide in the maternal blood, may 
prevent abortion. This is a suggestive and valuable observation. 

Haemoptysis may occur during pregnancy without phthisis or other 
organic disease. The cause is obscure but a knowledge of the fact may 
serve to lessen unnecessary anxiety. Perhaps this physiological vene- 
section may serve to ward off an impending toxaemia. 

COUGH IN GENERAL 

This, especially if severe, paroxysmal and prolonged, and whether 
due to whooping cough, influenza, measles, or simply to a bronchitis or 
an ordinary cold, is a highly undesirable symptom during pregnancy, and 
by its mechanical action may cause hemorrhage, detachment of the 
placenta, and eventually the interruption of pregnancy. It should be 
suppressed as promptly and effectually as is consistent with the interests 
of the patient. Sedatives, e.g., heroin or codeine, are usually indicated. 

DYSPNOEA 

As we have already seen, this is often present in slight degree, even in 
pregnancy approximately normal. Therefore in any affection in which 
oxygenation is interfered with, whether mechanically, as in capillary bron- 
chitis, or by the destruction of the red corpuscles, as in profound sepsis, 
the vitality of the patient is rapidly lowered, and the accumulation of 
carbon dioxide in the blood leads to the interruption of pregnancy by 
causing uterine contractions. In pneumonia we see both conditions present 
and we find premature labor the rule. 

Diseases of the Genito-Urinary Tract 

ACUTE nephritis 

Acute nephritis may develop during pregnancy, as at other times, but 
it is very rare. Of course, we have in the terminal stages of preeclamptic 
toxaemia and in eclampsia clinical symptoms and pathological lesions which 
can hardly be distinguished from those of acute nephritis, and if the 
physician is seeing his patient for the first time, the diagnosis may be 
difficult or impossible. If, however, he has been able to watch the case 
from the beginning, or if a complete history is accessible, he can usually 
make at least a presumptive diagnosis. In estimating the probabilities 
it is to be borne in mind that acute nephritis as a complication of pregnancy 
is much more infrequent than toxaemia or eclampsia, and that when it 
does occur there is usually a definite history of some one of the well-known 
causes of the condition, e.g., scarlet fever, septic infection, bichloride or 
other poisoning, etc. 



300 PATHOLOGY OF PREGNANCY AND LABOR 

The prognosis is serious, of course, and the treatment practically the 
same as that of eclampsia. 

CHRONIC NEPHRITIS 

This formidable disease may, of course, originate during pregnancy, 
but in the great majority of cases the process antedates pregnancy. In 
other words, the nephritis does not complicate pregnancy, but pregnancy 
complicates the nephritis. The differentiation of the condition from pre- 
eclamptic toxaemia has been discussed in connection with the latter con- 
dition. The prognosis is bad, and the earlier in pregnancy the symptoms 




Fig. 177. — Case of albuminuria. White infarcts of placenta which has been cut in sections and placed 

so as to show the fetal aspect. 

appear, the worse is the prospect. With well-marked evidences of nephri- 
tis in early pregnancy, it is very unlikely that either mother or child 
will survive its continuance until term. The extra work required of the 
kidneys is sufficient to account for the greatly increased danger to the 
mother, while hemorrhages, changes in the placental vessels, infarct for- 
mation, and maternal toxaemia help to account for the frequency of 
abortion, premature labor and still-birth. 

Treatment. — The above facts seem to show that the termination of 
pregnancy is indicated in these cases, and this conclusion is confirmed 



COMPLICATING AFFECTIONS 301 

bv clinical experience. If the patient is near the period of fetal viability 
and the disease is apparently stationary, one may wait a week or two in 
the hope of saving the foetus. The greatest care should be taken to 
distinguish the condition from preeclamptic toxaemia. The latter is much 
more frequent, is essentially a condition of the latter months of pregnancy, 
occurs in patients without a previous history of nephritis, and is usually 
promptly benefited by treatment. 

DIABETES 

In speaking of the urine in pregnancy we noted the fact that it often 
contains sugar, but that in many cases this is milk sugar, the result of 
absorption from the breasts, and need cause no anxiety. It has been 
shown recently, however, that small amounts of sugar can be detected 
in the urine of every pregnant woman, and that sugar ingested during 
pregnancy soon appears in the urine. This accounts for the fact, long 
familiar to clinicians, that pregnant women bear sugar badly. Various 
reasons for this have been advanced. Personally, I am inclined to agree 
with Hofbauer that it is due to certain changes in the liver that interfere 
with its glycogenic function, and that accompany most, if not all, 
pregnancies. ■ ■ 

Thus we see that the diagnosis of diabetes as a complication of preg- 
nancy rests not altogether upon the presence of sugar in the urine, but, 
as before, upon the clinical symptoms. The presence of milk sugar means 
nothing and even the presence of moderate quantities of grape sugar may 
be simply the so-called " alimentary '' or '' physiological " glycosuria, much 
more common in pregnancy than at other times. Whenever the latter is 
present, however, the patient should be carefully watched, and suitable 
dietetic and other treatment instituted. 

Fortunately true diabetes is rare in pregnancy. Williams was able to 
collect but sixty-six cases. In these, however, 50 per cent, of the mothers 
died ; about one-half of these at or within two weeks of the time of labor, 
and the other half within two years. In nearly one-half of the cases 
pregnancy terminated in abortion or still-birth. This would seem to 
indicate that in these rare cases the artificial termination of pregnancy is 
indicated. 

CYSTITIS 

Cystitis is rare during pregnancy, but, unfortunately, not infrequent 
during the puerperium. During pregnancy it may be an extension of a 
gonorrhoea, or, like pyelitis, it may be the result of infection by the colon 
bacillus. In the puerperium it is usually caused by the careless or unneces- 
sary use of the catheter. The symptoms are about the same as in the 
non-pregnant condition, but are far more likely to be followed by exten- 
sion to the ureter, and pelvis of the kidney. In the puerperium it is most 
frequently caused by the careless or unnecessary use of the catheter. This 
will be discussed later. 



302 PATHOLOGY OF PREGNANCY AND LABOR 

Treatment. — It is important that a cystitis be cured as soon as pos- 
sible, not only because of the attendant discomfort and exhaustion, but 
above all on account of the danger of the extension of infection to the 
ureter and pelvis of the kidney. My own preference is to irrigate the 
bladder with boric acid solution gr. xv to ^i and then to leave from four 
to six ounces of a 5 per cent, solution of argyrol in the bladder until the 
next urination, after the manner of Hirst. 

PYELITIS AND URETERITIS 

An inflammation of the ureter and pelvis of the kidney is not uncom- 
mon during pregnancy and the puerperium, and is probably due to stretch- 
ing or twisting of the ureters by the ascending uterus, or, after the fifth 
or sixth month, to the pressure of the uterus itself. Either of these 
factors may favor the transmission of an acute process, or may serve to 
light up a process previously existing. The organism most often at fault 
is the colon bacillus, though other organisms, notably the gonococcus, are 
often found. The inflammation of the ureter and pelvis of the kidney 
go together and are commonly known as pyelitis. 

The affection may develop at any time, but is usually observed during 
the latter half of pregnancy, or early in the puerperium. It is seldom 
seen before the fifth or sixth month, i.e., before the time when the pressure 
of the uterus begins to be felt. The right side is more often affected. This 
is explained by the usual right obliquity of the uterus, and by the fact 
that the presenting part usually occupies the right oblique diameter. 

Clinical History. — The patient first complains of pain, which is usually 
referred to the right iliac region, and is described as radiating to the groin. 
Palpation, however, reveals tenderness in the right lumbar region rather 
than in front ; a most important diagnostic sign. 

The temperature is elevated. Sometimes it is continuous, with an 
evening rise which may be slight or marked. Again it may be intermittent 
and accompanied by well-marked chills, the clinical picture reminding 
one of that of malarial fever, for which indeed it has often been mis- 
taken. The pulse varies with the temperature and presents no specially 
alarming features. 

Micturition is frequent, as in cystitis, but there is not the burning 
and smarting characteristic of the latter condition. The urine contains 
albumen, pus and bacteria in abundance. 

Internal examination shows that the enlarged and tender ureters can 
be palpated as they pass over the brim of the pelvis. If the patient has 
been delivered some degree of subinvolution will be noted. 

In the puerperium the factor of pressure is removed, but in its place 
w^e have the increased frequency of cystitis from the incautious or unneces- 
sary use of the catheter. Then, too, the possibility of its occurrence as 
part of a general blood infection is increased. The symptoms are much 
the same as in pregnancy but the affection assumes a somewhat more 



COMPLICATING AFFECTIONS 303 

acute character. The hectic type of fever reminds one of pysemic infection. 

The periods of chill followed by high fever doubtless correspond to 
the distention of the ureter with purulent urine. When the obstruction 
is relieved and the urine escapes, the temperature drops to normal, the 
pain disappears, and all the symptoms are relieved. The attendant con- 
gratulates himself upon the happy outcome, and all goes well for a day 
or two, when another chill and access of fever announce that the ureter is 
again obstructed. 

Diagnosis. — \Mth care this is not difficult. When the chills are severe 
and the fever intermittent the unwary may be led to make a diagnosis 
of malarial fever, or of pysemic infection, and the fact that the pain is on 
the right side may lead the attendant to suspect appendicitis, or infection 
localized in the parametrium, but in either case the urinary findings and 
the lumbar tenderness should be sufficient. There is a strange tendency, 
however, for a man who sees this affection for the first time to mistake 
it for something else. 

Prognosis. — The prognosis is good. The affection may be protracted, 
the temperature high, and all the symptoms well-marked, but final recovery 
is the rule. After the induction of labor, or after the completion of labor 
at term, there is usually a rapid subsidence of all the symptoms. In the 
puerperal cases the symptoms are more severe, but even here time usually 
suffices. Involvement of the kidney substance to such an extent that 
surgical interference becomes justified is very rare. 

Treatment. — Prophylaxis is important. During pregnancy the exter- 
nal genitalia should be kept clean by frequent ablutions with soap and 
water : gonorrhoea, if present, should be promptly treated, and cystitis as 
well. In the puerperium, the use of the catheter should be avoided if pos- 
sible, as advised in the section treating of the management of that period. 
If the use is unavoidable the most scrupulous care should be observed. 

The patient should remain quietly in bed and drink large quantities 
of water and vichy or other alkaline fluid. The diet should be bland and 
unirritating, consisting chiefly of milk. 

Among medicines urotropine enjoys a wide popularity. Five grains 
dissolved in a large glass of water may be given every four hours. Salol, 
helmitol, essence of turpentine and benzoate of soda have been used. 
Anodynes may be required for severe pain but should be used with discre- 
tion. It is important that the bowels be kept open and for this purpose 
a mild saline, e.g., citrate of magnesia, is indicated. 

An ice-bag may relieve the pain. If this fails hot applications, more 
agreeable to some patients, may be tried. Catheterization of the ureter 
and the injection of antiseptic solutions into the pelvis of the kidney have 
been advised but, unless in the hands of an expert urethroscopist, are 
likely to do more harm than good. Much safer and always easy to carry 
out is Pasteau's method of distention of the bladder, designed to excite 
peristalsis of the ureter and thus to facilitate drainage. The technic of this 



304 PATHOLOGY OF PREGNANCY AND LABOR 

method as given by Jeannin, who recommends it very highly, is as follows : 
The patient having urinated, 300 to 5CX) c.c. of tepid boric acid solution 
are introduced very slowly into the bladder, and the patient is encouraged 
to retain the solution for twenty minutes, when she is allowed to urinate 
a second time. The manoeuvre may be repeated two or three times a day. 

Hirst reports uniformly successful results with treatment by autoge- 
nous vaccines, and Polak gives similar testimony. 

The induction of labor is seldom indicated. It is, however, occasion- 
ally justifiable when other methods have failed and the general condition 
of the mother is seriously compromised, especially in those rare cases in 
which both kidneys are involved. 

In very rare cases nephrostomy (drainage) or nephrectomy (removal) 
of the kidney may be necessary. 

Gastro-ixtestixal Disturbances 

The gastro-intestinal system does not suffer as much as might be sup- 
posed during pregnancy. In fact, with the exception of the usual vomiting 
of pregnancy, which has nothing to do per se with the stomach, many 
women have a better appetite and digestion during pregnancy than at any 
other time. This is especially true of the second half of pregnancy. 
Nausea, vomiting and epigastric pain during the latter months are often 
symptoms of toxsemia, and should always lead to a careful urinalysis. 
Constipation is the most common and troublesome abnormality and this, 
together with other minor disturbances, is discussed in connection with 
the management of pregnancy. Of the toothache, gingivitis and salivation 
we have already spoken. 

Diarrhoea occurring in pregnancy may be a conservative process. 
Examples of this are seen in the toxaemia and in the vomiting of pregnancy. 
Even in the severe type of vomiting one sometimes sees rapid improvement 
follow an attack of diarrhoea. Aside from cases of this kind, however, and 
once the attendant is satisfied that the bowel is free from irritating material, 
purging and intestinal cramps should be promptly arrested. During preg- 
nancy they often cause severe shock, and they may be the cause of abortion 
or premature labor. In these cases a hypodermatic injection of morphine 
or pantopon not only relieves pain and diminishes shock but may prevent 
the interruption of pregnancy. 

The oxidative functions of the liver are taxed during pregnancy and 
this leads to various disturbances. Simple catarrhal jaundice may occur 
as at other times, but has no special significance. Jaundice during preg- 
nancy, however, is always a sinister symptom, as it may indicate the 
beginning of the liver degeneration which accompanies eclampsia and 
pernicious vomiting and characterizes acute yellow atrophy. Gall-stones 
are more frequent during pregnancy and the puerperium. No satis- 
factory explanation for this fact has yet been adduced. According to 



COMPLICATING AFFECTIONS 305 

'\\'illiams enteroptosis is often benefited by pregnancy, the descending 
viscera being held in position. The same writer quotes Maillart as affirm- 
ing that the improvement may sometimes be made permanent by the 
use of a moderately tight binder during the puerperium and a well-fitting 
abdominal supporter afterward. This is important, if true. 

APPENDICITIS 

This is easily diagnosed during the early months, and it is probably 
better for the mother to operate at once, especially if she has had an attack 
before. The operator should remember, however, that abortion is common 
after appendectomies, and the patient or those most interested should 
be informed of this fact. To prevent abortion, if possible, it is wise to 
avoid all handling of the uterus and ovaries and to administer morphine 
hypodermatically immediately after the operation. 

In the latter half of pregnancy conditions are unfavorable both for 
diagnosis and operative technic. It may be difficult to secure access to the 
field of operation. The presence of the pregnant uterus embarrasses the 
operator, and should labor supervene the retraction and descent of the 
uterus after delivery may result in rupture of an abscess, should one be 
present. For these reasons, unless the immediate performance of the 
operation is distinctly indicated, it should be deferred until after delivery. 

Diseases of the Nervous System 
general pruritus 

Though often classed as a cutaneous disease this is in all probability 
a neurosis, with perhaps a toxic substratum. Fortunately it is not common. 
The suffering of the patient may be extreme, especially at night, sleep 
becoming impossible. I recall a case in which after many sleepless nights 
the patient became hysterical and almost maniacal. Sedatives and hyp- 
notics were without effect and I was obliged to induce labor. Happily the 
child was viable and survived. 

Remedies to reduce peripheral irritation and induce sleep, e.g., chloral 
and the bromides, are indicated. Psychical treatment has been advised but 
is of little service. Hydrotherapeusis offers more hope of relief. 

LOCAL PRURITUS 

This affects chiefly the vulva and may be the source of great annoyance. 
In some cases it appears to be of neurotic origin but in others it can be 
accounted for by an irritating vaginal discharge or by diabetes. I have 
found an ointment composed of resorcin and oil of cade very useful in 
these cases. Gonorrhoea should be treated as already described. Cleans- 
ing alkaline douches may be helpful but should be used with caution on 
account of the danger of bringing on labor. 
20 



306 PATHOLOGY OF PREGNA^XY AND LABOR 

NEURITIS 

This is not uncommon during pregnancy. The symptoms are much 
the same as in the non-pregnant condition. The so-called gestational 
neuralgias, e.g., the toothache so often observed and the facial neuralgia 
of which these patients complain, are probably closely allied to this con- 
dition. It is fashionable at present to attribute these pains to some unex- 
plained toxaemia, and doubtless this is the cause in many cases, e.g., in 
the polyneuritis that accompanies the vomiting of pregnancy. They are, 
however, more common in early pregnancy and in anaemic subjects. The 
headache of preeclamptic toxaemia occurs in the latter half of pregnancy 
and is seldom unilateral. Neuralgic pains in the legs and thighs, due 
to the pressure of the child's head upon the nerves that pass over the 
brim of the pelvis, are common during the latter weeks of pregnancy, espe- 
cially, according to my observation, in the case of very large children. The 
non-indicated or unskilful use of the forceps may cause neuritis or even 
paralysis of long duration. Eventual recovery, however, is the rule. 
Neuritis has been observed in connection with pelvic exudations and with 
femoral phlebitis. In these cases pressure would seem to be the deter- 
mining factor. There is a form of neuritis which occurs during the lying-in 
period and involves especially the sciatic nerve, though it may affect the 
arms or trunk. There may be considerable inflammation and oedema of 
the affected limb. This form may occur in cases in which there has been 
no traumatism whatever, a point emphasized by Garrigues, and very 
important from a medicolegal stand-point. Not every case of neuritis or 
paralysis that follows delivery is the fault of the doctor. 

Analogous to the " nerve pains " of pregnancy are the transient 
paralyses so often observed. These may involve any part of the body, even 
the nerves of special sense. Loss of vision does not always mean impending 
eclampsia, though it should always excite the keenest attention of the 
physician and lead to a careful study of all the symptoms, including of 
course urinalysis. Sometimes it is due to anaemia of the retina. Again 
the condition may be one of hysterical amblyopia. In some cases but one 
eye is affected. Deafness may occur and involve one or both sides. Haemi- 
plegia or paraplegia may occur, but it is not usually organic, does not 
affect the progress of labor, and disappears during the puerperium. Even 
organic and incurable paraplegia, as elsewhere noted, does not necessarily 
prevent or delay parturition. 

Neuralgia of the muscles of the abdominal wall, the result of disten- 
tion by the growing uterus, is not uncommon. There is a tradition among 
the laity that this is benefited by anointing the abdomicn with oil. The 
practice seems to afford relief in some cases and is at all events quite 
harmless. 

The psychoses of pregnancy, labor and the puerperium will be discussed 
in the concluding chapter. 



COMPLICATING AFFECTIONS 307 

Cutaneous Diseases 

Pregnancy, per se, seems to have little connection with diseases of the 
skin. Pruritus as we have seen is probably neurotic or toxic in origin. 
Chloasma, already discussed, is undoubtedly of gestational origin and 
there are two other affections of which the same may be said. 

Herpes, appearing upon the extremities, more rarely upon the face 
and chest, is relatively common in pregnancy and is technically known as 
herpes gestationis. As in the case of the familiar herpes zoster it follows 
the course of the nerves. 

Impetigo herpetiformis is seldom seen in this country. Inflammatory 
areas are surmounted by pustules which, at first separate, become confluent 
later. The eruption occurs in the groins and upon the trunk, less often 
upon the limbs, seldom upon the face. The patches show a tendency to 
heal at the centre and extend at the periphery. The affection is attended 
by chills, high temperature, and general prostration. The cause is still 
a matter of speculation. The prognosis is bad. Mortality 75 or 80 per 
cent. Mayer reports success in three cases from the injection of 20 c.c. 
of the blood serum of a pregnant woman. 

Surgical Operations in Pregnancy 

Much has been said and written upon this subject. In a general way 
one may say that the old fear of operations during pregnancy has disap- 
peared and that it is now recognized that if an operation is distinctly indi- 
cated it is to be performed in pregnancy as at other times. This statement, 
however, requires certain modifications. We have already seen how in 
certain cases, e.g., in appendicitis and in certain cases of ovarian tumor 
complicating advanced pregnancy, operation is made much more difficult 
by the presence of the enlarged uterus and if not imperative is better 
postponed until after delivery. 

Then again certain operations, e.g., the two just mentioned, are pecu- 
liarly likely to be followed by abortion, and measures of prevention already 
described should never be omitted. This is most important, though seldom 
emphasized. 

During the operation the operator should never forget that he has 
under his care two patients. The duration of the anaesthesia should be 
strictly limited and the amount minimized. Ether should be given and 
there should be a large admixture of oxygen. Of dental procedures I have 
already spoken in connection with the management of pregnancy. 



CHAPTER XV 
THE PREMATURE INTERRUPTION OF PREGNANCY 

When pregnancy is interrupted before the period of viability of the 
foetus, i.e., approximately, before the end of the sixth month, the process 
is termed an abortion. When it is interrupted between the period of via- 
bility and the normal termination of pregnancy, it is called premature 
labor. Its termination during the second trimester was formerly known 
as a miscarriage, but the term has been abandoned as without scientific 
meaning. It may be used, however, in speaking with the patient or her 
family, since the term abortion is so often associated with criminal 
practices that it has acquired a sinister and offensive sound. 

Etiology. — To mention here every illness or accident that might 
conceivably be the cause of abortion is manifestly impracticable. We may, 
however, group the causes as follows: i. Maternal causes, which may be 
either general or local ; 2. fetal causes ; 3. incidental causes ; 4. criminality. 

Among the general maternal causes syphilis, as we know, takes the lead. 
Here the constitutional disease produces changes in the placenta that lead 
to the death and final expulsion of the foetus, and the immediate cause of 
abortion is after all a local one. In the acute infectious diseases the 
process is analogous. For example, in typhoid the bacillus may find its 
way to the foetus, which contracts the disease, dies, and is finally expelled. 
More commonly the foetus is destroyed by the toxins of the disease. In 
nephritis, and other conditions of high arterial tension, placental apoplexies 
may interfere with the exchange between mother and foetus, causing the 
death of the latter. Cyanosis occurring in the course of cardiac or renal 
disease may result in the death of the foetus from lack of oxygen ; or the 
high accumulation of carbon dioxide in the maternal blood may stimulate 
the uterus to contract. High temperature also stimulates the uterus to 
contract, especially when it comes on suddenly as in scarlet fever. In 
the last two instances the uterus contracts as a resulu of external causes. 
In the instance first mentioned it contracts as a result of the death of the 
foetus. In some cases we may have more than one factor. For example, 
in pneumonia, in which premature labor is the rule, we may have toxins 
in the maternal blood, cyanosis, and high fever coming on suddenly. 

The reader may well ask here, " Why does the death of the foetus 
result in its expulsion? " This question has not as yet been satisfactorily 
answered. To say that the ovum has become a foreign body sounds plau- 
sible but explains nothing. Wliy the uterus contracts when the foetus dies 
is as much a riddle as why it expands when the foetus lives. However, 
the fact remains. 
308 



PREAIATURE INTERRUPTION OF PREGNANCY 309 

Then again c-ertain symptoms of disease tend to excite uterine con- 
tractions by mechanical irritation. Examples of these symptoms are 
coughing, vomiting, straining, convulsive movements, etc. 

Local Changes. — Of the local changes which lead to abortion endo- 
metritis is by all odds the most frequent. Here again it is the death of the 
foetus that affords the impulse to uterine contraction. In cases of retro- 
flexion, prolapse and other displacements the abortion is attributed to the 
displacement, but this is more often due to the accompanying endometritis. 
This also is true of tumors which do not encroach upon the uterine cavity. 
In the case of the latter, however, and in the case of uterine malformations 
it is easy to see how the premature distention, due to the insufficient size 
of the uterine cavity, leads to vigorous contractions and the final expul- 
sion of the uterine contents. In the same way it is not difficult to under- 
stand how the stretching of old adhesions, the result of some inflammatory 
process, may altord the reflex impulse to similar contractions. 

Fetal and Placental Causes. — Of those causes which have to do with 
the ovum primarily, but not necessarily with the death of the foetus, faulty 
insertion of the placenta is the most common. It is doubtless the unrecog- 
nized cause of many early abortions. Multiple and molar pregnancy are 
other examples. 

Incidental Causes. — There are certain accidental causes which are best 
classified by saying that they do not belong to any particular class. Among 
these are any severe mental or physical exertion, various drugs, long rail- 
road journeys, driving over rough roads, bicycling, blows, shocks, various 
kinds of traumatism, surgical operations, etc. 

Criminality. — Every physician soon learns that a large proportion 
of abortions are premeditated, intentional, and without justification. This; 
nefarious Avork is performed in our large cities by " quack " doctors, 
by many midwives, and very often by the patient herself. It is unfor- 
tunately true that some who aspire to the reputation of being engaged 
in the honorable practice of medicine are not overscrupulous in this matter. 
It often happens that the perpetrator of the crime, having initiated the 
process of abortion, lacks the courage or the knowledge to finish his work. 
The abortion has become inevitable and the remainder of the process must 
be supervised by some physician engaged in legitimate practice. These 
" incomplete abortions " soon become familiar to the ambulance surgeon 
and the young practitioner. Sometimes the ovum has been punctured but 
the bulk remains in ufero, or, again, the foetus has been expelled and the 
placenta remains. 

Paternal Causes. — We hear sometimes of paternal causes. If the 
husband has syphilis and transmits the disease to his wife, or child, 
abortion may of course result, but here the father is, strictly speaking, 
the occasion, rather than the cause, of the abortion. Again, we know that 
some men are sterile, and it has been assumed that certain men may 



310 PATHOLOGY OF PREGNANCY AND LABOR 

procreate an ovum that has not the power of survival. This, however, 
remains to be proven. 

Irritable Uterus. — Some women are prone to abort upon sHght occa- 
sion, or for no cause discoverable by superficial examination. Such 
patients are often said to have the " abortion habit " or to be the victims 
of what is sometimes called " irritable uterus." It is probable that in a 
large proportion of these cases a more thorough examination would 
reveal some undiscovered cause, e.g., some chronic constitutional disease, 
or a chronic endometritis. 

Mechanism. — In labor at term the foetus is so large that it constitutes 
the chief obstacle to delivery. All the problems of the mechanism of labor 
centre about the position and movements of the foetus. This is true 
though in a lesser degree of the last five months. In the first four months, 
however, it is the decidua or the placenta that constitutes the bulk of the 
ovum. An appreciation of this fact is necessary if one would understand 
the mechanism or the treatment of abortion. 

In the first two months the thick and very friable decidua is gradually 
separated from the uterine wall by the uterine contractions and after 
sufficient dilatation of the cervix the ovum is expelled entire. The tiny 
embryo, lost in the mass of decidua, usually passes unnoticed. The process 
requires much less time in multiparse than in primiparae since the resistance 
of the external os has been overcome in a preceding labor. In a primipara, 
however, the external os may offer a stout resistance and the process be 
long and painful, lasting for hours or even days. In certain cases the 
ovum may be arrested in the cervix, the internal os recontracting to some 
extent and the dilatation of the external os being delayed. The ovum 
remains imprisoned in the now spindle-shaped cervical canal ; the so-called 
'' cervical abortion." This also may continue for a long time. In these 
cases we speak of the expulsion of an " intact ovum." It should be 
remembered, however, that the uterine decidua is retained. This fact, as 
we shall see presently, has an important bearing upon the treatment. 

In the first two months then, the expulsion of the intact ovum is the 
rule. To this rule, however, there are many exceptions. The sac may 
be ruptured before the cervix has become dilated or the decidua has become 
separated from the uterine wall. This is the case in a large proportion 
of criminal abortions in which the puncture of the membranes is often 
the first step. 

In the first two to two and one-half months the decidua constitutes 
the great bulk of the ovum and the principal danger to be feared is the 
retention of decidua. Abortion at this stage is called by the French, 
ovular abortion. I am in the habit of calling it decidual abortion, a name 
which at once describes the condition and suggests the treatment (Fig. 
178). 

At about two and one-half months placental formation is complete, 
the amnion and chorion are easily separated and decidual atrophy has 



PREMATURE IXTERRUPTION OF PREGNANCY 311 

become marked. The foetus, though more noticeable than before, is rela- 
tively small but the placenta has become relatively large and now con- 
stitutes the great bulk of the ovum. The principal complication to be 
feared is retention of the placenta. Obviously the best name for this stage 
is that of placental abortion. Here there is usually little chance of the 
escape of an intact ovum. 

The presenting part of the ovum usually ruptures, the foetus is expelled, 
carrying with it the decidua reflex, while the placenta and decidua vera are 
retained. ]\Iore rarely the foetus is expelled alone, the placenta and mem- 





FiG. 178. — Decidual abortion. 



Fig. 179. — Placental abortion. 



branes remaining in ttfero; or the physician may find on his arrival that 
the foetus, placenta and membranes have all been extruded (Fig. 179). 

In the fifth and sixth months the foetus has grown so large that it fills 
the greater part of the uterine cavity and the so-called abortion has become 
a veritable labor in miniature. There is no longer any special danger of 
retention, either of placenta or decidua. The foetus, though not large 
enough to constitute a serious obstacle to delivery, plays the principal 
role. When the foetus has been delivered the rest is usually easy. 

I earnestly advise the student to learn these simple facts with reference 
to the classification and mechanism of abortions, believing that they will 



312 PATHOLOGY OF PREGNANCY AND LABOR 

do much to clarify a subject which, for some reason, many men seem 
never to master at all. 

How shall we divide abortions clinically? Here the old classification 
is satisfactory. Every abortion of whatever variety is threatened, inevi- 
table, or incomplete. The first two terms explain themselves, the third 
has already been explained. 

Clinical History. — The chief symptoms are pain and hemorrhage. 
The " pains " are recurrent, like those of labor, but more irregular. In 
primipar^e they are often quite severe, and when the ovum is arrested in 
the cervix the suffering may be constant and extreme. Once the bulk of 
the ovum has escaped into the vagina the pain suddenly ceases. More 
or less hemorrhage usually continues, however, until the uterus is empty, 
especially in cases of retained placenta. 

Vaginal examination shows enlargement of the uterus corresponding 
to the probable period of pregnancy. Some men forget all about this. 
The large boggy anteverted body of the corpus uteri is easily felt in the 
anterior cnl se sac. It is not unusual for patients even in the midst of 
an abortion to deny the fact of pregnancy. Cervical dilatation may not 
have progressed far enough to permit the introduction of the finger. If 
in this case the examiner finds that the cervico-uterine angle has been 
effaced, i.e., that the cervix is no longer a cylinder but a cone, the junction 
of the cervix and the body of the uterus not being felt, there is little doubt 
that an abortion is well in progress. This valuable sign, easy to elicit 
and of great value, should be carefully studied by the beginner in obstetrics. 

Now and then in the case of a primipara the ovum remains for hours 
in the long cervical canal from which, owing to the resistance of the 
external os, it cannot escape. It is this resistance, already overcome in 
the case of a woman who has borne a child, that makes an abortion in a 
primipara such a tedious and painful affair. 

At a later stage the finger can be passed through the cervix and made 
to touch some part of the ovum, or if this has been expelled, to palpate 
the interior of the uterus and to recognize placental tissue if present. 

Having determined that the patient has some symptoms of abortion the 
question at once arises. Is abortion inevitable ? This is an important ques- 
tion because the treatment employed in one case is radically different from 
that employed in the other. If the abortion can be prevented, it is the duty 
of the physician to prevent it ; if it is inevitable the process should be 
hastened as much as is consistent with the safety of the mother. 

If the cervical canal has become effaced, or if the evidences of cervical 
abortion are present, or if the finger passed through the cervix recognizes 
some part of the ovum in the region of the external os, abortion is to be 
regarded as inevitable. 

If with severe and recurring pains there is free hemorrhage abortion is 
to be regarded as almost certain. 



PRE^^IATURE INTERRUPTION OF PREGNANCY 313 

On the other hand, if pain and hemorrhage are shght, and, above all, 
If the canal of the cervix is preserved in its entire length, and its point of 
junction with the corpus uteri is plainly appreciable, the case is to be 
regarded as a threatened abortion and every effort made to arrest its 
progress. 

Diagnosis. — There can hardly be any difficulty in diagnosis provided 
we are certain of the existence of pregnancy. This is to be determined 
by the signs already given. Of course the history is valuable if it is 
reliable. Unfortunately one not infrequently meets cases in which all 
history of pregnancy is denied, and this even though the patient presents 
unmistakable evidences of abortion in active progress. 

A fibrous polypus in process of extrusion is a possible source of error 
since there is dilatation of the cervix and a foreign body may be felt. I 
have known two or three instances in which this curious mistake was 
made. 

One may be for a time uncertain whether a profuse and painful men- 
struation may not be an abortion at four weeks. If subinvolution is present 
the uterus will be somewhat enlarged, simulating the uterus of early 
pregnancy. Here one may be obliged to wait for a day or two. If the 
finger can be passed through the cervix something more than mere 
menstruation must be present. 

Whenever the finger can feel some part of the ovum through the 
external os the diagnosis is easy. 

All clots or other uterine debris should be carefully exam.ined under 
water and the patient should be instructed to save whatever is passed from 
the vagina. Unfortunately, it is the rule that everything has been carefully 
disposed of before the arrival of the physician. 

The beginner should remember that, in threatened or actual abortion, 
the blood is bright red. A discharge of brownish-red fluid is a common 
symptom of decidual endometritis and is often compatible with the 
continuance of pregnancy. 

Tubal abortion has often been mistaken for ordinary abortion. Here 
again the difference In the treatment makes a mistake in diagnosis a very 
serious matter. Hence the following cardinal rule, In every real or 
suspected abortion the condition of the adnexa should he determined by 
careful bimanual examination. 

By the observance of this rule the attendant not only guards against 
the danger of overlooking a tubal abortion, but against the danger of 
neglecting the presence of an Infectious process In the parametrium. 

Treatment. — The treatment of abortion Is either preventive or curative. 
The preventive treatment should on no account be forgotten. 

Syphilis, the most common cause, should be treated by the methods 
already described. Nor should the treatment of the husband If necessary 
be forgotten Morbid constitutional states, and especially anaemia from 



314 PATHOLOGY OF PREGNANCY AND LABOR 

whatever cause, should be treated. In certain doubtful and ill-defined 
conditions complete change of air and scene is attended by satisfactory 
results. 

Local disabilities should receive expert attention. Endometritis should 
receive appropriate treatment. It is a matter of common experience that 
a thorough dilatation and curettage are often followed by conception in 
women who have been married for several years without conceiving. I 
have learned to have little patience with prolonged treatment by tampons, 
etc. Cervical tears should be repaired, uterine malpositions corrected, etc. 

In a word, the patient should receive such local treatment as she may 
require, and should then be placed in the best possible general condition. 

If conception happily follows she should, as far as possible, avoid all 
the causes of abortion already mentioned. 

Patients predisposed to abortion should avoid all physical, mental and 
emotional strain and refrain from sexual intercourse, especially at periods 
corresponding to the menstrual epochs. They should carefully guard 
against constipation, but should avoid all drastic cathartics, especially the 
popular castor oil, which has a peculiar tendency to excite uterine con- 
tractions. The fluidextract of viburnum prunifolium, one-half drachm 
four times a day, seems to be useful as a uterine sedative. Beginning 
the employment of this remedy with some skepticism I have become 
convinced of its usefulness. 

If slight pain and discharge appear, the patient should be put to bed 
and kept quiet by the use of morphia in full doses. Its action is deepened 
and prolonged by combining it with hyoscine or the bromides. Viburnum 
may be given at the same time, but in my opinion it is a mistake to defer 
its use until symptoms of threatened abortion appear. When a predis- 
position to abortion exists it should be used to prevent the appearance of 
such symptoms. The patient should be kept quiet and the treatment only 
gradually discontinued. The bowels should be kept open by simple enemata 
or by mild laxatives like the magnesium citrate. No douches, no tampons, 
no ice-bags. All these things tend to cause uterine contractions. If the 
bleeding is so severe as to require them, there is little hope of arresting 
the process and the case is to be treated as one of inevitable abortion. The 
patient should be kept under careful observation during the remainder 
of her pregnancy. 

While there is general agreement as to the preventive treatment of 
abortion, the curative treatment still remains a questio vexata. Many 
students of the subject, myself included, have been perplexed and embar- 
rassed by the varying and conflicting views of teachers and writers. After 
considerable experience I have settled upon a method of treatment which 
I do not hesitate to recommend to my readers. It is based upon ana- 
tomical conditions and has given such good results in my hands that I 
would be very loath to discard or materially modify it. 

In the first place there are two dangers to be combated : hemorrhage 



PREMATURE INTERRUPTION OF PREGNANCY 315 

and infection. The latter is the more serious one and is to be met, here 
as elsewhere, by a careful observance of the rules of asepsis. Modifi- 
cations of these rules adapted to the treatment of abortion will be discussed 
as we go on. It is highly desirable to limit the amount of hemorrhage to 
the minimum. A fatal result from hemorrhage in these cases is not 
common, but such a result is by no means impossible and not infrequently 
the patient loses so much blood that her convalescence is prolonged and 
her future health impaired. 

Unlike normal labor abortion is an unnatural process. Nature, inter- 
rupted in her work, has not found opportunity to provide for the prompt 
and complete emptying of the uterus. Retention of portions of the ovum 
is a predisposing cause of infection and a direct cause of hemorrhage. 
The foetus is of course not viable and can therefore be disregarded. 

The indication then in every inevitable abortion is to empty the uterus 
as soon as this can be done without injury to the mother. Not, as many 
seem to imagine, at any cost or at whatever sacrifice. 

Recalling that, as we have just seen, the contents of the uterus and 
the mechanism of their expulsion differ at different periods of pregnancy, 
it is obvious that the treatment will also differ. 

If the attendant is convinced that the case is one of inevitable abortion 
the emptying of the uterus is indicated. How shall it be accomplished? 
TJiis depends upon the condition of the cervix. 

If the cervix is sufficiently dilated uterine contents should be removed 
with the finger. During the first two months the introduction of one 
finger is sufficient. I have read the statement that as a necessary prelimi- 
nary the cervix should be dilated until it admits two fingers. If this advice 
is follow^ed in all cases many bad cervical tears will result. During the 
first two or two and one-half months one finger is sufficient. 

Technic. — The patient should be in the dorsal position with bladder 
and rectum empty. The external genitalia should be carefully cleansed 
with soap and water and lysol solution. Preliminary douching is in my 
experience quite unnecessary. 

The operator now proceeds to the digital removal of the uterine con- 
tents. How is this to be accomplished ? The text-books tell us to pass the 
finger up to one cornu of the uterus, then carry it across to the other and 
then downward, sweeping the uterine contents before it. This sounds well 
hut many an operator has discovered that, without further explanation, 
it is difficult or even impossible. Indeed, if the uterus is in a condition 
of marked anteflexion, as it usually is at this time, and is allowed to remain 
so, the procedure advised is a mechanical impossibility. I have usually 
succeeded in the following manner : The finger passed through the internal 
OS makes traction upon the anterior cervical lip, thus retroverting the 
uterus and bringing it into line with the vagina (Fig. i8o). The external 
hand now makes strong pressure over the fundus, pushing the uterus down 
over the finger, when the bulk of the ovum can usually be removed in the 



316 



PATHOLOGY OF PREGNANCY AND LABOR 



manner described. This simple manoeuvre, which is the product of my 
own experience and which has doubtless occurred to many others, I 
have never seen illustrated or described. 

All large fragments of ovum and placenta are to be removed by the 
finger, which then palpates the uterine interior in order to assure the 
examiner that the bulk of the uterine contents has been removed. 

Do not try to do this with the curette. Certainly not after the first 
month. It is unsafe and ineffectual. Some men think they can tell what 
is in the uterus with the curette, but this is a delusive belief. Large masses 




Fig. i8o. — Showing manner of bringing uterus in line with vagina. 

of placenta have often been removed after this kind of curettage, not 
to speak of cases in which the uterus has been perforated. 

But the educated finger can tell. Whenever opportunity offers the 
beginner should practise the manoeuvre under the direction of a more 
experienced colleague in order that he may not be embarrassed at his 
first case. Now and then the canal of the cervix has not been obliterated 
and resists all efforts at dilatation. The fingers can feel, but not grasp, the 
placental bulk. Lender these circumstances the cautious use of the placental 
forceps is permissible. In order to avoid the danger of seizing the uterine 
wall the instrument should not be carried far above the internal os. Any 
attempt to push it to the fundus is dangerous. During its employment it 
should be guided and controlled by the finger. 



PRE:^IATURE interruption of pregnancy 317 



After the separation of the placenta there is always left a roughened 
surface at the placental site. This, of course, should not be made the 
subject of curettage or of attempts at removal. It is highly important that 
the beginner be made acquainted with this fact, but a review of the text- 
books shows that it is mentioned by only one other. 

The whole procedure may be made much easier by passing the entire 
hand into the vagina, and if the operator has a small hand and the patient 
is a multipara with lax and capacious vagina this may be done, but 
under ordinary circumstances it is a barbarous 
procedure and capable of producing serious 
laceration. 

Should the curette be used, and, if so, when, 
and in what cases ? With reference to this point 
there is much confusion and much difference of 
opinion. My own custom is as follows : If 
pregnancy is of less than three months' duration 
I use the sharp or half-sharp curette carefully 
but thoroughly. This is not always necessary, 
but in the great majority of cases gives the best 
results. \\^hile Bumm and Winter have shown 
that the retained decidua vera may be restored 
to normal mucous membrane, this is the excep- 
tion, especially after the first month. The re- 
tained decidua keeps up the bleeding and pre- 
disposes to infection. Some writers, while using 
the curette, would limit its use to the first two or 
two and one-half months. I have been accus- 
tomed to treat all cases in which pregnancy is 
apparently of less than three months' duration 
as belonging to the decidual period, and believe 
this to be the safest course. We never know 
the exact date of conception or the precise 
degree of embryonal development. 

I am convinced that this treatment not only arrests hemorrhage, 
minimizes the danger of infection, and materially shortens the period of 
convalescence, but prevents the endometritis and menorrhagia so common 
after early abortions. 

The curette should be of good size. Not smaller than that shown in 
Fig. i8i. For general use the half-sharp curette is the best. A very small 
instrument is inefficient and dangerous. It may penetrate a sinus, or 
gouge or even penetrate the uterine wall. Moreover, the larger instrument 
can be located after it enters the uterus. 

The curette should be held with the thumb and finger and carried very 
gently to the fundus. The down stroke may be moderately firm. The oper- 
ator should go over the ground systematically ; first the anterior wall, then 




Fig. i8i. — Curette, natural size. 



^ 



318 



PATHOLOGY OF PREGNANCY AND LABOR 



the sides and the posterior wall. The cornua should not be neglected. 
Before every curettage the position of the uterus should be carefully 
determined. Fig. 182 shows what might result from neglect of this 
precaution. 

Every physician who does much obstetric work should be provided 
with a suitable curette and should know how to use it ; but this knowledge 
cannot be obtained from books. Every prospective obstetrician should 
perform the operation at least once or twice under suitable direction and 
control as part of his regular preparation for practice. 

I am in the habit of giving a single intra-uterine douche of hot salt 
solution after the uterus has been emptied, whether by the finger or 
curette. In my experience this serves to wash out any decidual or placental 




Fig. 182. — Perforation of retrofiexed uterus. 

debris that may remain, stops bleeding, and secures prompt and firm uterine 
contraction. It is not absolutely necessary, however, and it should not be 
repeated. 

Draining the uterus with gauze, i.e., leaving a strip of gauze in the 
uterus with one end projecting into the vagina, is a common and I believe 
a very pernicious practice, favoring as it does the transmission of infection 
from the vagina to the uterus. Indeed the conditions thus created are 
very similar to those which obtain when the membranes are retained and 
left hanging from the cervix. Drainage is not needed in these cases. As 
Polak has well said, a uterus in normal position will drain itself. 

Nor is it usually necessary to pack the uterus. If the uterus is empty 
the bleeding will cease spontaneously. If the bleeding continues it will 
usually be found that the uterus was not properly emptied. Very rarely, 
however, a lax uterus will bleed even though empty. In this case it should 



PREMATURE INTERRUPTION OF PREGNANCY 319 

be packed with gauze, as described in the section on the treatment of post- 
partum hemorrhage. I have met but one case in which this was necessary. 

After the third month there is Httle or no use for the curette, certainly 
not for the sharp curette. The decidua vera has now atrophied and it is 
placental retention that is to be feared. The finger and occasionally the 
placental forceps are used. 

After the fourth or fifth month the secundines are expelled as in normal 
labor and no special precautions are necessary. 

Up to this time we have been considering cases in which the cervix 
admits one or two fingers. But suppose that the cervix is only slightly 
dilated and the hemorrhage profuse. This is a case for the tampon. A 
sterilized gauze bandage is as good as anything for this purpose. The 
cervix and lower uterine segment should first be packed and then ^tlie 
vagina, and the whole should be held in place by a T-bandage. Instru- 
mental dilatation is unnecessary and dangerous, as I have tried to show 
in the chapter on the induction of abortion, which the reader is advised to 
review in connection with this subject. The tampon may be removed in 
about twelve hours, when the cervix will usually be found well dilated. 
The uterus is then emptied as already described. 

Not infrequently the patient has lost a large quantity of blood before 
the physician's arrival. In these cases extreme care is indicated. If an 
anaesthetic becomes necessary ether or nitrous oxide should be used. The 
treatment of acute anaemia, as detailed in the chapter on postpartum hemor- 
rhage, should be carried out in every detail and in particular the venous 
or subcutaneous infusion of salt solution should not be too long delayed. 
It is not common for a patient to die from hemorrhage under these circum- 
stances, but it is by no means impossible. 

After-treatment. — The patient should remain quietly in bed for a week 
or ten days. Too early getting up is a fruitful source of subinvolution and 
subsequent uterine disease. No douches should be given. Scrupulous 
external cleanliness is sufficient. An ice-bag over the uterus for the first 
few days is a wise precaution. It serves to promote uterine contraction, 
allays pain and soreness, and possibly helps to inhibit bacterial develop- 
ment. Small doses of ergot, ten or fifteen minims every three or four 
hours, are also useful. A favorite prescription of mine at this time is ergot 
and hydrastis, ten minims three or four times a day. 

Let me briefly summarize what I believe to be the most important facts. 

When the cervix will admit the finger the latter is to be used for the 
removal of all large masses. The cautious use of the placental forceps is 
allowable. 

If dilatation of the cervix is necessary the tampon is to be preferred 
to the steel dilators, except in cases of great emergency. 

If pregnancy is of less than three months' duration it is wise to use 
the curette after the uterus has been emptied by the finger. After this 
the curette is not indicated. The curette should not be used in septic cases. 



320 



PATHOLOGY OF PREGNANCY AND LABOR 



No gauze should be left in the uterus or vagina after delivery except in 
case of hemorrhage from a relaxed uterus. 

No bichloride, carbolic or other poisonous solution, should be used for 
intra-uterine irrigation after delivery. 

Ether is to be preferred to chloroform, especially when there has been 
much bleeding. 

Rubber gloves should be worn and changed when necessary and every 
effort made to insure rigid asepsis. 

The ice-bag and ergot are valuable to promote involution. 

Mention must here be made of several curious phenomena all depend- 
ing upon the retention, in iifero, of certain products of conception. Of 




Fig. 183. — Ihrombus at placental site, simulating polypus. 

these the most remarkable is that which is known as missed abortion. This 
phenomenon was made much of by the older waiters and was probably 
much more common than it has been since the prompt emptying of the 
uterus has become a matter of routine. 

The prompt success of modern methods of treatment has led us to 
think of abortion as a process that always goes on to completion. This, 
however, is not the case. The uterus does not always empty itself. The 
contractions may cease after a time, the cervix recontract, and the product 
of conception be retained. If, in the meantime, hemorrhage takes place 
into the ovum itself we have an accumulation of blood between the vera 
and reflexa. and between the amnion and chorion. The resulting mass 



PRE.AIATURE INTERRUPTION OF PREGNANCY 321 

made up of ovum and blood clot may be retained for some weeks, or even 
months. At first the mass is red and is called a blood mole. Later it 
becomes lighter in color and is then known as a flesh mole. These moles 
are sometimes retained for months and the foetus may become macerated, 
mummified, or even petrified, the amniotic fluid being absorbed meanwhile. 
The petrified foetus or lithopaedion, as it is called, is the result of the 
deposition of lime salts and is very rare in ordinary pregnancy, though it 
occurs somewhat more frequently in extra-uterine pregnancy. 

When the placenta is retained its rough surface favors the coagulation 
of the blood which comes into contact with it and the result may be a 
thrombus, which gradually increases in size until it fills the uterine cavity 
and projects from the cervix like a polypus; whence the name placental 
polypus (Fig. 183). 



21 



CHAPTER XVI 

EXTRA-UTERINE PREGNANCY 

The subject of extra-uterine pregnancy occupies the borderland between 
obstetrics and gyn3ecolog}^ It is a remarkable fact that many writers of 
obstetric text-books, while devoting scant space to, and giving little in- 
formation about, the most important and the most frequently performed 
of the purely obstetric operations, forceps, version, the Csesarean sec- 
tion, and the like, occupy a large space with the consideration of the 
minutiae of this subject. Indeed, it is hardly too much to say that some 
writers have given more attention to extra-uterine pregnancy than to 
pregnancy that is normal. 

It is my observation that many practitioners and students regard extra- 
uterine pregnancy as an obscure subject to be reserved for specialists in 
gynaecology, and to be seriously studied only as a preparation for ex- 
amination. Perhaps this is because of the disproportionate space so often 
allotted to the histopathology of the subject and to its endless bibliography. 
Whatever the cause it is a grave error and at some unexpected moment 
may result in disaster. Extra-uterine pregnancy is more common than 
twin-pregnancy and occurs alike in hamlet and hospital. Its main clinical 
phenomena and the guiding principles of its treatment are easily learned 
and should be constantly borne in mind. 

The subject is considered at length in every text-book on gynaecology, 
and I will content myself here with a brief review of the essentials. 

In the higher mammals, and presumably in man, the ovum and sper- 
matozoon meet in the Fallopian tube, and the fecundated ovum, urged on 
by the ciliary current and probably also by the contractions of the muscular 
coat of the tube, finds its way into the uterine cavity, there to^ undergo 
further development. When for any reason it does not reach the uterus 
but remains and develops outside its cavity, the result constitutes what is 
known as extra-uterine pregnancy. Ectopic gestation and tubal pregnancy 
are terms often, but incorrectly, used as synonymous. 

Frequency. — Extra-uterine pregnancy was formerly supposed to be of 
rare occurrence, but with better methods of diagnosis it is now known to 
be quite common. Pelvic haematocele, once described as an independent 
disease, is now known to be almost always the result of extra-uterine preg- 
nancy. Many cases of tubal abortion pass unrecognized or are mistaken 
for ordinary abortions. Perhaps it is not too much to say that I per cent. 
of all pregnancies are extra-uterine. 

Classification. — In the vast majority of cases extra-uterine pregnancy 
begins in the tube. Tubal pregnancy may be tubo-uterine, isthmic, am- 
pullar, or tubo-ovarian. These terms are largely self-explanatory. In 
322 



EXTRA-UTERINE PREGNANCY 323 

tubo-uterine pregnancy the ovum is lodged in that part of the tube which 
passes through the uterine wall. The tubo-uterine variety is rare. Next 
in frequency is isthmic pregnancy. Ampullar pregnancy is the most com- 
mon of all. Few cases of ovarian pregnancy have been observed. Primary- 
abdominal pregnancy is no longer recognized. Difficulties in classification 
will disappear if we remember that, with the exception of ovarian preg- 
nancy, all forms of extra-uterine pregnancy are either modifications or ex- 
tensions of tubal pregnancy, both abdominal and broad ligament pregnancy 
being always secondary. Tubo-ovarian pregnancy usually begins in the 
tube and extends to the ovary. A^ery rarely the reverse is the case. 

Etiology. — Strangely enough, but little is known as to the causes of 
extra-uterine pregnancy. Among those suggested are malformations, de- 
velopmental anomalies of the tubes, pressure from tumors, peritoneal 
adhesions, etc. 

Somewhat more plausible is the idea that inflammatory changes, usually 
gonorrhoeal, constitute the chief factor. It has been suggested that the 
existence of a decidual reaction in the tube is found as an atavistic tendency 
in certain individuals, and that these are predisposed to tubal pregnancy. 
This theory, as well as that which refers the condition to shock, mental, 
emotions, etc., is purely speculative. 

It is known that an ovum from one ovary may have crossed the pelvic 
cavity and entered the opposite tube, and it has been conjectured that during 
its transit it may grow too large to pass the contracted portion of the tube. 

It is easy to see that many writers in seeking the causes of tubal preg- 
nancy have reasoned from analogy rather than from actual experience. 
It is fair, how^ever, to assume that tubal or uterine disease is in a general 
way a predisposing cause, since cases are apt to occur after a comparatively 
long period of sterility. This is about all that can be said at present. 

Terminations. — The usual termination of tubal pregnancy is tubal 
abortion. It occurs in about seventy-five per cent, of all cases. Next in 
frequency is tubal rupture, and, rarest of all, the persistence of pregnancy 
until term. Tubal rupture is usually followed by the death of the foetus, 
but in exceptional cases pregnancy continues. If the foetus dies and is not 
removed by operative procedure, it may, if small, be completely absorbed. 
If not, it may undergo mummification or calcification. If bacteria gain 
access to the sac it may suppurate with the formation of adhesions to sur- 
rounding structures and the discharge of the foetus, piecemeal, into the 
intestine, vagina, or bladder. 

Tubal Abortion. — By tubal abortion is meant the rupture of the ovum, 
without rupture of the tubal wall. The hemorrhage is within the tube. 
The ovum may be completely, or only partially, detached (complete or 
incomplete tubal abortion). Partial detachment is more likely to occur 
when the ovum is located at the isthmus on account of the contraction of 
this part of the tube. In these cases the process is protracted, or ceases 
altogether, hemorrhage continuing, with the formation of a tubal mole. 



324 



PATHOLOGY OF PREGXA^XY AND LABOR 



In the ampulla there is more likely to be complete detachment of the 
ovum, with extrusion of the latter into the peritoneal cavity. The hemor- 
rhag-e is usually confined to the lumen and immediate vicinity of the tube. 
In cases of profuse hemorrhage, however, the entire pelvic cavity may be 
filled. Coincidently with tubal abortion there occur some of the symptoms 
of ordinary uterine abortion, e.g., painful uterine contractions, dilatation of 
the cervix, and the discharge of a structure resembling the decidua of 
normal pregnancy. 

Tubal Rupture. — The penetration of the thin wall of the tube by the 
fetal elements results in the establishment of a weak spot which readily 
yields to mechanical violence, stretching of the tubal wall by the growing 
ovum, overdistention from hemorrhage, straining efforts, etc. Rupture 





Fig. 184. — Broad ligament pregnancy. (Zweifel.) 

usually occurs, if at all, before the third month, and according to its 
location the eft'used blood will escape into the peritoneal cavity or into the 
space between the broad ligaments. This is true also of the ovum, the 
result being either an abdominal or a broad ligament pregnancy (Fig. 184). 
If the ovum is expelled intact, or if the foetus is completely separated from 
its placenta, the foetus dies, but if the placenta remains attached, the foetus 
may survive. In such cases the placenta becomes much enlarged, and is 
attached to the adjacent peritoneal surface over a wide area. 

With complete maturity of the foetus the placental circulation ceases, 
spurious labor ensues, and if artificial aid is not afforded, the foetus dies 
and undergoes the changes already noted. 

Clinical History and Diagnosis. — The early symptoms and signs of 
extra-uterine pregnancy resemble very closely those of normal pregnancy, 



EXTELVUTERINE PREGNANCY 325 

already described. The uterus is enlarged and there are the usual changes 
in the cervix and vagina. The breasts increase in size and, most significant 
of all, menstruation is delayed. I say delayed, because in the majority of 
cases a little irregular bleeding is noticed before the time for the second or 
third period has elapsed. There may be occasional attacks of faintness or 
vertigo. All these symptoms are significant if present, but unfortunately 
they are often absent. 

Additional symptoms of great importance, when recognized, are pain 
in the aft'ected side and the presence of a tumor in the same location. These 
latter symptoms, however, are usually, or at least often, distinguished by 
their absence. Pain may be slight or absent and it is often difficult or 
impossible to map out the tumor before the third month. Here skill in the 
bimanual examination counts for much and in a difficult case the prac- 
titioner will do well to avail himself of expert advice. There are some 
men whose sensitive touch enables them to recognize the soft fluctuation 
of the distended tube when it is quite imperceptible to others. 

But a word of caution is necessary here. All manipulations should be 
gentle, since the sac has been ruptured many times in the course of a bi- 
manual examination. An accident of this kind may result in severe 
hemorrhage. Bumm reports two cases of this kind. It is also^ evident that 
such an examination should never be made under an anaesthetic. If the 
patient is conscious she may be relied upon to give warning against too 
strong compression of the sensitive mass. 

On the whole then, it is not strange that competent and careful observers 
are sometimes in doubt. The bimanual examination does not always give 
positive results, and there may be no definite subjective symptoms. Very 
often the condition is accidentally discovered in the course of a laparotomy 
performed for some other indication. In careless or incompetent hands 
it is usually diagnosed as normal pregnancy, and if a hemorrhage occurs 
it is regarded as a threatened abortion. In view of these facts, it is evident 
that every case of pregnancy which runs a course in the least atypical 
should be carefully studied, and that the appendages should be carefully 
palpated in every supposed case of uterine abortion. 

Then, too, the history of the case is of considerable value. Very sig- 
nificant, as we have already seen, is a history of previous uterine disease, 
and especially of gonorrhoea. That extra-uterine pregnancy often follows 
a long period of sterility is an ancient observation. 

To make a mistake in the diagnosis of this condition is a serious matter, 
and the practitioner will do well to examine all doubtful cases with care 
and to secure without delay such advice and assistance as he may deem 
necessary. 

Alany cases go on unrecognized until the occurrence of tubal abortion 
or tubal rupture serves to sharply remind the attendant and all concerned 
that something unusual is in progress. 

What are the symptoms of tubal abortion? In most cases very much 



326 



PATHOLOGY OF PREGNANCY AND LABOR 



the same as in ordinary uterine abortion. There is, of course, no ovum 
passed, but in its place a decidual cast or fragments of decidua. The pain 
is intermittent and is referred to the pelvic, lower abdominal, or ovarian 
regions. There is moderate hemorrhage. In the majority of cases the 
symptoms are slight and are overlooked or regarded as the evidences of an 
ordinary abortion. There may, hoAvever, be severe pain and marked 
tenderness over the affected tube, and, occasionally, the constitutional signs 
of severe hemorrhage. These cases can hardly be differentiated from those 
of tubal rupture. 

After an abortion has taken place the tumor is so increased in size, 
owing to the effusion of blood, that it can be easily felt. 




Fig. 185. — Anterior hasmatocele. 

The discharge of decidual membrane is usually considered of much 
diagnostic importance, but its significance is of positive, rather than nega- 
tive, value. AVilliams has shown that it is sometimes cast off and replaced 
by normal endometrium at an early period of extra-uterine gestation. 

Rupture of the Tube 

This is characterized by the suddenness of its onset and by the severity 
of the symptoms. Following sharp pain in the side, which, however, is not 
always present, symptoms of acute anaemia rapidly develop. The face is 
pale and drawn, the pulse rapid and feeble, the surface of the body is 
bathed in a cold perspiration, the patient calls for more air, In a word the 



EXTRA-UTERINE PREGNANCY 



327 



clinical picture is one of severe internal hemorrhage (Figs. 185 and 186). 

External examination reveals, in addition to general tenderness, the 
presence of fluid, as shown by dulness in the flanks when the patient lies 
upon her back and tympanitic resonance in the middle where the intestines 
float upon the contained fluid. Then, too, the location of the area of 
dulness varies with the position of the patient, since the fluid naturally 
gravitates to the lowest level, and the gas-filled bowel to^ the highest (Fig. 
187). The presence of free blood in the peritoneal cavity may be con- 
firmed by the aspirating needle, or better, perhaps, by an incision in the 
posterior cul de sac. 

Vaginal examination shows that the uterus is depressed as a whole, and 




P'lG. 186. — Posterior haematocele. 



palpation of the posterior cul de sac may reveal some tension resistance to 
the examining finger, but no distinct tumor formation. In bad cases the 
condition of the patient becomes progressively worse and evidences of 
haematocele formation are wanting. On the other hand, if conditions are 
favorable, the pulse and general appearance gradually improve, and the 
increasing resistance, together with the gradual development of a tumor in 
the vaginal vault, betoken a favorable result. If the blood has been effused 
into the broad ligament, a tumor will be found at one side of the uterus 
displacing the latter to the opposite side, while if a pelvic haematocele is 
formed there will be general resistance in the posterior cul de sac, and the 
uterus will be fixed and immobile. 



328 



PATHOLOGY OF PREGNANCY AND LABOR 



A sign justly emphasized by Polak, though seldom mentioned by others, 
is sensitiveness of the cervix to motion. ]\Iovement in any direction causes 
pain, due to dragging upon the overstretched and inflamed peritoneal 
surfaces. 

Meanwhile the resources of the laboratory are not to be forgotten. 
Blood examination shows that both the amount of hsemoglobin and the 
number of red corpuscles are reduced. Moderate inflammatory reaction 
in the peritoneum results in an increased leucocyte count. These are of 
value in the less acute cases where a slow bleeding is going on for days 
(the reader should not forget the existence of these cases, even though 




Fig. 187. — Hemorrhage into the peritoneal cavity. 

they are rare), but in the acute cases, of the type just described, there is 
little time to wait for them. 

Advanced Extra-L'terixe Pregnancy 

The diagnosis of advanced extra-uterine pregnancy should present no 
difficulty to the careful observer. The history of the case, together with 
the presence of a comparatively large tumor which can be separated from 
the uterus, usually suffices. As the months pass the foetus, lying as it does 
directly beneath the abdominal wall, may be recognized, even by the tyro. 
The fetal heart sounds can be heard and the fetal parts felt, with startling 



EXTR.VUTERINE PREGNANCY 329 

distinctness. Pain and shock, almost unendurable, may be caused by fetal 
movements. The uterus may be felt to contract separately from the 
timior, and the peritoneal irritation caused by the presence of the relatively 
enormous foreign body results in alternating attacks of constipation, diar- 
rhoea, and colic. Passing a sound into the uterus has been practised as a 
diagnostic measure, but should hardly be necessary except in cases of 
advanced tubal pregnancy, which is of necessity accompanied by persistent 
hypertrophy of the tubal musculature. In these cases strong contractions 
are felt in the tube, so strong, indeed, that they may be mistaken for uterine 
contractions. In the other varieties of extra-uterine pregnancy the sac 
does not contract, and the fact that the uterus may be made to contract 
separately by friction constitutes an important element in the diagnosis. 
Of course, the uterus is much smaller than it should be in advanced 
pregnancy. 

Differential Diagnosis. — The condition with which tubal abortion is 
most commonly confounded is ordinary uterine abortion; but in the latter 
condition the pains are regular and increase progressively in frequency, 
while in tubal abortion they are irregular and spasmodic. Moreover, in 
tubal abortion, the blood is slight in amount, and although there may be a 
decidual cast or fragments of decidua, there are, of course, no chorionic 
villi. In tubal abortion the blood is slight in amount, dark in color, and 
does not contain clots, while in uterine abortion there is a profuse flow of 
bright red blood with abundant clots, and chorionic villi, as well as decidua, 
can be demonstrated, not to speak of portions of the foetus. The demon- 
stration of a mass at the side of the uterus makes the diagnosis almost cer- 
tain, but unfortunately this is not always practicable. 

Retroversion of the gravid uterus has been mistaken for extra-uterine 
pregnancy, but is distinguished from it by the prominence of bladder 
troubles and retention of urine. No competent observer should make this 
mistake. In both cases, of course, there are the subjective and some of the 
objective signs of early pregnancy. In retroflexion, however, the bladder 
symptoms, frequent and painful urination, retention, dribbling, are 
prominent. The fundus is absent from its usual position. 

As elsewhere noted, pregnancy in the rudimentary horn of a bicornate 
uterus cannot be distinguished from extra-uterine pregnancy, but as the 
treatment in both cases is the same this is a matter of academic interest only. 

A^'arious conditions which may cause swelling or pain in the parametrium 
or iliac fossa, including ovarian cyst, pyosalpinx, and many others which 
it is hardly necessary to cite here, even including appendicitis, have led to 
confusion. They are not accompanied by the subjective or objective signs 
of pregnancy, however; the cervix is not patulous, and the uterus does not 
contain decidua. Moreover, the sudden and tragic collapse which attends 
tubal rupture and bad cases of tubal abortion is absent. 

Every case of abortion should be considered as possibly one of tubal 
abortion, and the reader should not forget the possible, though extremely 



330 PATHOLOGY OF PREGNANCY AND LABOR 

rare, coexistence of extra-uierine pregnancy with normal pregnancy, and 
the possibiHty that nomial pregnancy may be comphcated by an adnexal 
tumor, e.g., ovarian cyst. 

•Nor is it to be forgotten that a moderate leucocytosis accompanies extra- 
uterine pregnancy, a fact of importance when some inflammatory condition 
is suspected. 

In aU cases of doubt it is best to keep the patient under careful observa- 
tion, preferably in a hospital. /\n excess of caution can do no great harm, 
while indifference or neglect may be attended by the most serious con- 
sequences. 

Treatment. — This is best considered under three heads : 

1. Treatment in the early months before abortion or rupture. 

2. Treatment of tubal abortion and tubal rupture. 

3. Treatment of advanced pregnancy. 

1. In the early months, before either abortion or rupture has occurred, 
the treatment consists in laparotomy and the removal of the ovum together 
with the affected tube. The chances of the ultimate survival of the child 
are so small, and the danger to the mother involved in the continuance of 
pregnancy so great, that temporizing is the height of folly. Certain writers 
have recently advised attempting to save the tube by incising it, removing 
the ovum, and sewing up the incision. The value of this procedure is still 
sub judice. 

2. In the case of abortion or rupture the treatment will depend upon 
the condition of the patient. In most cases of abortion there are no special 
symptoms and no treatment is required. Indeed, tubal abortion often 
passes unnoticed by the patient, who regards it as an ordinary menstrual 
period. Occasionally the symptoms are very severe, and the treatment is 
the same as for uterine rupture, from which in such cases it can hardly be 
distinguished. 

Treatment After Rupture. — This has recently become a matter of dis- 
pute. It was formerly the custom to operate immediately in all cases, and 
at first thought this seems the only logical method. I am convinced, how- 
ever, that immediate operation, especially in hands not over skilful, has 
sometimes turned the scale in the wrong direction. The question is com- 
plicated by the fact that it is not always possible to differentiate tubal 
abortion from tubal rupture, or to determine how much of the apparent 
gravity of the case is due to shock, and how much to hemorrhage. Statis- 
tics are fallacious. If an operation is performed and the patient dies, it is 
said that the operation was performed too late. If no operation is per- 
formed and the patient dies it may be said that an operation would have 
saved her life. ]\Iuch depends upon the ability of the attendant, both as 
diagnostician and operator. Robb believes that it is better to defer the 
operation, claiming that death as an immediate result of the hemorrhage 
is rare, and that the patient should be allowed to recover from the shock. 
Polak, after an extensive experience, Is of the same opinion. 



EXTRxVUTERINE PREGNANCY 331 

Perhaps the situation may be thus summed up. If the patient is not 
plainly /;/. extremis, if the operator is competent, and if the diagnosis is 
positive, immediate operation is the safest course. If the operator is in 
doubt or the patient appears to be holding her own, it is better to wait, 
meanwhile keeping a careful watch upon the pulse and general condition. 
The patient is kept quiet, the foot of the bed is raised, and morphine 
administered hypodemiatically. A jMurphy drip is installed. The latter 
has the advantage of slowly restoring the volume of the circulation without 
starting the bleeding afresh. Active stimulation is to^ be avoided, since this 
may also cause renewed bleeding. If the threatening symptoms subside, as 
they often do, a waiting policy is to be pursued. If not, operation should 
on no account be delayed. 

Technic. — ^Little time need be lost in preparation. The operative field 
is painted with tincture of iodine without previous washing. A median 
incision is made and the hand carried directly to the uterus, which is at 
once delivered through the abdominal incision. Two clamps are applied to 
the adnexa of the affected side ; the first near the uterus, and the second 
near the pelvic wall. As soon as the abdomen has been opened there may 
be profuse hemorrhage, but the operator should not allow this to disconcert 
him. Recalling that this blood has already been lost to the circulation and 
that its further escape can do the patient no harm, he should proceed care- 
fully but rapidly. After the clamps have been applied the hemorrhage 
ceases, and the operator has more leisure to tie the ovarian vessels and 
unite the cut surfaces of the broad ligaments. The abdominal wound is 
then closed by a few interrupted sutures of silkworm gut. No great time 
should be spent in attempting to clear the peritoneal cavity of all traces of 
blood, the presence of which does no harm, or at least not as much as 
would the prolongation of the operation. Two or three pints of hot salt 
solution may be left in the peritoneal cavity. This is rapidly absorbed and 
helps to restore the volume of the circulation. Furthermore, the presence 
of the hot solution helps to minimize shock. The abdominal wound is 
closed by a few interrupted sutures of silkworm gut. During the operation 
saline solution may be injected under the breasts. The anaesthetic should 
be ether oxygen. Morphine should be used hypodermatlcally to lessen the 
amount of ether required. Only a few drops of the latter may be necessary 
and its administration should be discontinued as soon as possible (Fig. i88). 

If the general condition Improves and evidences of haematocele, as 
shown by tumor formation In the cut de sac of Douglas, develop, an ice-bag 
serves to relieve pain, and perhaps to diminish the risk of further bleeding. 
Meanwhile the patient Is kept quiet in bed and supportive treatment Insti- 
tuted. Active catharsis Is avoided, but the bowels are kept open by water 
or oil enemata. Later, absorption may be hastened by hot vaginal douches, 
and perhaps by massage. 

The attendant must not fancy that all danger is over. The bleeding 
may begin anew or the hasmatoma may become the seat of Infection. In 



332 



PATHOLOGY OF PREGNANCY AND LABOR 



the former case the abdomen should be opened and the offending structures 
removed. Here the vaginal route is not suitable, work done in this way 
being necessarily imperfect. If, however, the hasmatoma becomes the seat 
of infection, it is better to make a free incision in the cul de sac and pack 
this lightly with sterile or mildly iodized gauze, thus avoiding the trans- 
mission of infection to the peritoneal cavity. 

Since the adoption of modern methods of treatment, the management of 
advanced extra-uterine pregnancy has become a problem with which even 
the specialist seldom has to deal. Nowadays one seldom sees advanced 




Fig. li 



-Tubal pregnancy. Clamp applied to broad ligament at the uterus. 



cases even in hospital or consulting practice. The distinguishing features 
of these cases are, first, that the child is alive; second, that the fetal sac 
is adherent to many surrounding structures, and last and most important 
of all, that the placenta is attached to structures that do not contract as does 
the uterus in normal labor, and that hence the normal safeguards against 
hemorrhage are absent. 

These facts not only render the operation a difficult one, but make it 



EXTILVUTERINE PREGNANCY 333 

more difficult as times goes on, and from the stand-point of the mother, the 
earlier it is performed the better. Before the period of viability of the 
child there can be no doubt as to the propriety of operative interference, 
and even after this period has been reached the parents should be informed 
of the perils of further delay. 

The disposition of the placenta presents a difficult problem. It may be 
attached extensively to the intestines and an attempt at removal involves 
not only the danger of very serious hemorrhage but also of extensive 
laceration of the gut. It is. therefore, better in the majority of cases to 
tampon the operation wotmd with sterile gauze, leaving the placenta in situ 
to come away naturally. 

There are cases in which the sac is pediculated or completely enclosed 
within the layers of the broad ligament and in these cases the operation is 
unexpectedly easy. No one can foretell this, however, and it is obvious 
that, whenever possible, the patient should be removed to a hospital for 
operation. 



CHAPTER XVII 
ANOMALIES OF THE FCETUS AND ITS APPENDAGES 

The study of fetal anomalies and monstrosities belongs to the domain 
of teratolog}^, and from the stand-point of pure science is very interesting, 
but in a practical work on obstetrics it should not detain us long. We will 
consider here only those forms which are of clinical importance or special 
interest. 

Hydrocephalus 

Among these the most common is hydrocephalus {Hydrocephalic, 











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■'^mi 


"■ 1 


f 


^f^ 


/^ 






/ 
/ 
/ 


y 




V J J 


' 




{. 20 cent. 






\ '-■'- 


■"-...-''' f 


tD 


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n 

1 



Fig. 189. — Signs of hydrocephalus during pregnancy. Fundus high. 

Wasserkopf ) . Every man w4io does much obstetrical work meets an occa- 
sional case of this anomaly. The name tells most of what we know about 
the essential condition. There is an over-accumulation of the cerebro- 
334 



axo:malies of the fcetus 



335 



spinal fluid in the ventricles of the brain. As a result the head becomes 
enlarged, sometimes enormously, perhaps two or three times its normal 
size. The bones of the skull are thinned to a notable degree, the sutures 
are much wider and the fontanelles much larger. 

Etiology. — Little or nothing is known as to the cause. The condition, 
however, is often associated with other abnormalities, e.g., spina bifida or 
club foot. 

Influence Upon Labor. — As might be expected, the course of labor is 




Fig. 190. — Palpating the hydrocephalic head. 

profoundly influenced. The first stage is tedious, the cervix dilates slowly, 
and after a time, perhaps, dilatation ceases altogether. It is possible for a 
hydrocephalic head of considerable size to become so^ moulded as to enter 
or even pass the pelvic brim, and now and then the cranial vault, its thick- 
ness reduced almost to the vanishing point, bursts, and the fluid is expelled, 
the head collapsing as after craniotomy. Such occurrences are rare, how- 
ever, and cannot be depended upon. In the great majority of cases the 
condition constitutes an insuperable bar to normal delivery. The head 
cannot enter, much less pass, the brim, and if the condition is not relieved. 



336 



PATHOLOGY OF PREGXAXCY AND LABOR 



either by nature or art, exhaustion, sepsis, or rupture of the uterus super- 
venes. The latter accident is especially frequent. According to Fabre 
these ruptures, which are almost always fatal, usually originate at that point 
Avhere the forehead impinges most prominently against the uterine wall, and 
where the tension is naturally greatest. 

Diagnosis. — This is an important matter, since a mistake may result in 
serious consequences. A^aluable information may be obtained by external 
examination. The head will be found much enlarged and well above the 
brim, even though the patient be a primipara. The body is relatively small. 
The dorso-occipital angle, as I have ventured to term it, is marked and 

unmistakable, reminding one of 
face presentation. The shoulder 
is felt, and the fetal heart heard, 
if at all, at a higher level than 
usual — in the neighborhood of 
the umbilicus. As might be ex- 
pected breech presentation is not 
uncommon. Protrusion of the ab- 
domen is somewhat more marked 
than in uncomplicated cases. On 
palpating the head a crackling 
sensation, like that which one 
feels in palpating the head of a 
dead foetus, is often appreciated. 
The condition is often over- 
looked by those who do not prac- 
tise external examination as a 
routine measure, but can hardly 
escape observation by one who 
uses modern methods. 

Whatever doubt remains is dis- 
sipated by the internal examina- 
tion. The sutures and fontanelles 
are widened and enlarged, sometimes enormously. The great size of the soft 
fluctuating cranium and the relatively small size of the face can hardly es- 
cape attention. Since, however, the head is high and difficult to reach it may 
be necessary to introduce the hand into the uterus before one can make a 
satisfactory examination and a positive diagnosis (Figs. 190 and 191). 
If there is unexpected delay in the delivery of the after-coming head, 
one should always think of the possibility of hydrocephalus, especially in 
the case of a premature child, since in these cases the delivery of the small 
after-coming head is, under normal conditions, always easy. If the child 
has spina bifida, or club foot, the possibility becomes practically a certainty. 
Prognosis. — This is good if the condition is recognized in time and 
properly treated. If not, it is indeed gloomy, for, except in the rare cases 




Fig. 191. — Hydrocephalic after-coming head. 
Extracted by means of crotchet in the mouth. 



ANOMALIES OF THE FOETUS 



337 



in which the head molds or bursts, the case will terminate in one of the 
ways already mentioned. ]\Iany cases of rupture of the uterus have been 
reported. 

Treatment. — If the disproportion is very great we are usually driven 
to the cruel alternative of perforation. It is better to endeavor first to 
aspirate the fluid with an aspirating needle or a fine trocar and to avoid as 
far as possible the neighborhood of the cerebral sinuses. Many of these 
children have lived to grow up, and the physician has no right to constitute 
himself executioner because the 
child may be an imbecile. With 
the evacuation of the fluid the skull 
collapses and the efiforts of nature 

may be sufficient to accomplish ^ • "^ 

delivery. 

Perforation of the after-coming 
head may prove difficult. In this 
case one may exsect a piece of one 
of the cer\acal vertebrae and pass a 
catheter through the spinal canal. 

ACEPHALUS OR AxENCEPHALUS 

This is the converse of hydro- 
cephalus and much more rare. In 
this variety the entire cranium is 
lacking. The condition is illustrated 
in Fig. 192. It is likely to make 
trouble in the diagnosis of position 
and presentation. I recall the case 
of a patient near term, in which I 
was unable, after careful palpation, 
to feel the head through the abdom- 
inal wall, although there seemed no 
reason why palpation should be diffi- 
cult in this particular case. Some 
time later the patient was delivered of an acephalic foetus. I had not 
been able to feel the fetal head because there was no fetal head to be 
felt. In the acephalic foetus all that remains of what under other cir- 
cumstances would be the cephalic pole is the face. Vaginal examination 
reveals nothing characteristic. The condition has been mistaken for breech 
presentation. 

Treatment. — The first stage is likely to be prolonged since the acephalic 
head is a poor dilator of the cervix. If delay should occur the best treat- 
ment would be version, since there could be none of the usual trouble with 
the after-coming head. 
22 




Fig. 192. — Acrania and anencephah 



338 



PATHOLOGY OF PREGNANCY AND LABOR 



Double Monsters 

No one has seen enough of these cases to be able to formulate rules 
derived from experience, and any attempt to reproduce here all the mal- 
positions and malpresentations which might occur with the treatment of 
each would be a species of pedantry bordering closely on the ridiculous 
(Fig. 193). 

L'xusuAL Abdominal Enlargement 

This condition may prevent or complicate delivery. Among the causes 
that have been noted are cysts of the kidneys, retention of urine, and 

ascites. When the enlargement is due to an 
increased fluid content simple " tapping " 
of the foetus is sufficient. If this does not 
suffice thoracotomy or evisceration may be 
necessary. 

General Dropsy of the Foetus 
This is rare, but is of considerable im- 
portance clinically, since it may be the 
source of delay in labor. The condition is 
one of general oedema of the foetus and 
placenta. The foetus is still-bom, or at best 
lives but a few hours. We have no definite 
information as to the cause of the condition. 

Rigor Mortis 
This phenomenon occurs within as well 
as without the uterus. Its existence at 
birth is, of course, evidence that death 
occurred some time before delivery and 
thus excludes most cases of late asphyxia 
and of injury during operative delivery. 
As might be expected, rigor mortis renders delivery, w^hether normal or 
operative, more difficult by interfering with those movements of flexion 
and adaptation so essential to its normal progress and completion. 

Abnormalities of the Placenta 

By far the most important of these from a clinical stand-point is 
placenta praevia. Next in order comes hemorrhage from the normally 
implanted placenta. Both are discussed in connection with the puerperal 
hemorrhages. 

placenta succenturiata 

Next in importance are the placentae succenturiatae (Fig. 194) or 
accessory placentae (Nebenkuchen of the Germans), small masses of 
placental tissue developed upon the chorion at some distance from the 




Fig. 193. — Helen and Judith, ischiopagse. 



AXO^IALIES OF THE FCETUS 



339 



border of the true placenta. They are usually overlooked by those who 
do not make a careful examination of the placenta and membranes in 
every case. Their presence is announced by the discovery of vessels torn 
across at the placental border. In some cases (and this is usually for- 
gotten) these connecting vessels are absent and the only clue is found- 
in defects in the membranes — an additional reason for examining the latter. 
The reader will recall that these defects will be in the chorion, therefore 




FiG. 194. — Placenta with three succenturiate placentae. 



not only the margin but the entire surface of the membranes should be 
examined in a good light. An irregularly round or oval aperture in the 
chorion, with raised edges and vascular connections, denotes that a succen- 
turiate placenta remains in the uterus. It is true, of course, that the signs 
above mentioned are seldom observed and the practitioner may look a long 
time, perhaps a lifetime, without finding them. Nevertheless it is wise to 
look. An hour or more must, or at least should, be spent with the patient 
after delivery and but a few minutes need be occupied by these precau- 
tions. Moreover, these anomalies are occasionally found and the protection 



340 



PATHOLOGY OF PREGNANCY AND LABOR 



afforded to the patient is not altogether theoretical. By care in this respect 
the attendant not only forestalls criticism but is better prepared to treat 
infection should it occur. Last, but not least, he is cultivating habits of 
care and scientific accuracy which will cling to him through his professional 
career and be of incalculable value to his patients and himself. 

PLACENTA MEMBRANACEA 

A rare placental anomaly is the attachment, or as it were the " spreading 
out," of the placenta over the entire chorion instead of over the serotina 




Fig. 195. — Placenta tripartita. (After Hyrtl.) 

only. The clinical importance of this anomaly is that it may make manual 
removal of the placenta necessary. 

PLACENTA CIRCUMVALLATA 

In certain cases there is an elevated whitish circular border along the 
placental margin which has nothing to do with infarct formation, but is 
caused by the infolding of the membranes. The mechanism of its pro- 
duction is not well understood. The condition is known as placenta 
circumvallata, and is of some clinical significance, inasmach as it may 
retard the separation of the placenta after delivery, and predisposes to 
the retention of the membranes, which may be torn all round the placental 
border and retained in toto. 

PLACENTA DUPLEX, PLACENTA BIPARTITA, ETC. 

Sometimes in place of a single placenta there are two placentae, united 
only by a membranous septum, and with no vascular connection. Here 



AXO^IALIES OF THE FCETUS 



341 



one speaks of a duplex placenta, or, if there are three similarly connected, 
of a triplex placenta ; and so on. As many as seven have been noted. 
Again, the placenta may be divided into two parts, the vessels, how- 




FiG. 196. — Placenta septuplex. (After Hyrtl.) 




Copyright, 1912, D. Appleton i*e Co. 

Fig. 197. — Placenta bipartita. (After Williams.) 



ever, extending from one part to another, as in Figs. 195 and 196. These 
conditions are rare, but it is wise to recall the possibility of their occurrence 
and to examine every placenta carefully (Figs. 197 and 198). 



342 



PATHOLOGY OF PREGXANXY AND LABOR 



INFARCTS OF THE PLACENTA 

Under this familiar heading we recognize a condition with which every 
obstetrician is clinically familiar — white or yellowish-white masses of 
varying size and shape scattered throughout the placenta. According to 
Williams, Eden and others, they are due to obliterating endarteritis of 
the chorionic villi. But what is the ultimate cause ? 

A^on Franque attributes them to endometritis, while Hitschman regards 
the process as the physiological preliminary to placental separation at term. 
DeLee suggests, and it seems to me with good reason, that they are simply 
the usual vascular changes of nephritis affecting the placental blood-vessels. 

They are constantly found in nephritis and other conditions of high 




Copyright, 1912, D. Appletvn & Co. 
Fig. 198. — Placenta duplex with two succenturiate lobules. 



(After Williams.) 



tension. It is self-evident that when at all extensive they must interfere 
with the nutrition and oxygenation of the foetus. 

Now and then a white band composed of infarcts will be found 
extending around the placental margin — placenta marginata. This resem- 
bles the placenta circumvallata, previously mentioned, but has nothing in 
common with it except the resemblance. 

Sometimes the infarcts are of a dark or bright red color and sur- 
rounded by a fibrous capsule (red infarcts). These are found in nephritics 
and albuminurics. 

Tumors and foreign growths of the placenta are rare. The most 
common is the myxoma fibrosum placentae of Mrchow. Sarcoma has been 



ANOMALIES OF THE FCETUS 



343 




^ / 



3 ^ 
a- 




344 



PATHOLOGY OF PREGNANCY AND LABOR 



observed. Most tumors of the placenta are the result of the hypertrophy 
of the vessels and may be grouped under the general heading of chorio- 
angiomata. Cysts of the placenta result from the breaking down of infarcts 
or of the trophoblastic cells, which make up the bulk of the decidual septa 
(Williams). 




Pig. 201. — Velamentous insertion. (After Hyrtl.) 

Anomalies of the Cord 

The placenta insertion of the cord varies. It may be, in the order of 
frequency, eccentric, centric, marginal or velamentous. In the eccentric 
form the cord is inserted between the margin and the centre of the 
placenta. In the centric form at or very near the centre. In the mar- 
ginal form at the margin. In the velamentous insertion the vessels 
separate before reaching the placental margin and run for some distance 
covered only by the membranes, as shown in Fig. 201. This insertion 



ANOMALIES OF THE FCETUS 



345 



is more common in twin-pregnancy. A\'iUiams found in 2000 cases 
that the relative frequency was as follows : Eccentric, 73.25 per cent. ; 
centric, 1S.25 per cent. ; marginal, 7.25 per cent. ; velamentous, 1.25 per cent. 
Of these insertions only the last named is of clinical importance. If 
in a case of low implantation of the placenta the uncovered vessels of the 
cord come to lie in front of the head they may be compressed with result- 



// 



O 




^^i^>/' 



r.u 



'■) } 



<rf 



ing asphyxia of the foetus. 

The cord may vary very 
much in length. Cases have 
been recorded in which the 
cord was absent. In these 
cases its place was taken by 
an umbilical hernia. The 
longest cord on record was 
198 centimetres. 

Knots in the cord are of 
two kinds, false and true. 
The false knots are caused 
by varicosities of the um- 
bilical veins, or arterial 
nodes, and while they look 
like knots are in reality 
not knots at all. The 
true knot, which is the 
result of the child's pass- 
ing through a loop in the 
cord, is a very different 
thing, and now and then 
causes the death of the 
foetus. Sometimes the cord 
is twisted. The number of 
twists may be enormous. 
Schauta reports 380 in one 
case. They occur mostly in 
premature and dead chil- 
dren and have no special 
clinical significance. They 
are said to occur more frequently in male children, which seems an absurd 
conclusion. Cysts of the cord are common but of no practical importance. 

The length of the cord is a matter of considerable clinical importance. 
A short cord may cause delay in the second stage of labor. It may also 
cause complete or extensive detachment of the placenta with dangerous 
hemorrhage. Shortness of the cord may be absolute or relative. If a 
cord of average length is twisted two or three times around the child's 
neck it is to all intents and purposes a short cord. 




Fig. 202. — Cystic degeneration of villi of the chorion. 



346 



PATHOLOGY OF PREGNANCY AND LABOR 



Diseases of the Chorion 

iiydatidiform mole ( cystic degeneration of the chorionic villi) 

Of the various abnormalities of the chorion the one possessing- most 
importance is cystic degeneration of the chorionic vilH, otherwise known 
by the clumsy but ancient appellation of hydatidiform mole. 







Fig. 203. — Uterus containing a vesicular mole. (Ahlfeld.) 



Pathology. — The appearance is characteristic and not to be forgotten. 
A\'ithin the decidua, which covers it like a hood, is a great mass of cysts 
of various sizes. Some of them are as large as grapes, or even larger, and 
often so arranged as to remind one of clusters of grapes. These cysts are 
filled with a clear fluid containing mucin and albumin. Now and then 




Degenerated tufts belonging to twin ovum Normal placental tissue 

Fig. 204. — Partial myxoma of the placenta. 

an amniotic sac with its contained embryo is found in the midst of the 
mass but more often there is no trace of one, although the maternal portion 
of the cord may be recognized (Figs. 203 and 204). If the degenerative 
process does not begin until after the formation of the placenta it may 
involve but a small part of that organ and pregnancy may continue. This 
is well shown in Fig. 204. Virchow taught that the condition is a myxoma 



ANOMALIES OF THE FCETUS 347 

of the chorionic vilH, but later investigations have shown that the process 
begins in the two epithehal layers, the syncytium and Langhans's layer, 
involvement of the mucous tissue being secondary. 

Etiology. — Nothing definite is known as to the cause of this con- 
dition. Endometritis is probably a predisposing factor. It appears, how- 
ever, that the condition may in some cases be of fetal origin, since in the 
case of twins one may escape while the other becomes converted into a 
mole. There is no lack of ingenious hypotheses, but certainty is lacking. 
The condition may occur in extra-uterine pregnancy and it may coexist 
with polycystic degeneration of the ovaries. It is in many cases the 
precursor of deciduoma malignum (Fig. 205). It is plain that if we 
kncAv all about the patholog}^ and etiology of this condition we would be 
able to clear up some of the mys- 
teries that still cloud the physiol- ' - ' 
ogy and pathology of pregnancy. '*"--^^ ' > " 

Frequency. — The condition is 
not common and few practitioners, '\\fr, v v- '" --'^ 

even among those who practise ^ -3^^ 5-^ l^'^^'f'^'^v ' 

obstetrics as a specialty, have o"^ i "~" - -'^^"^ '^' *''^ "i* 
seen many examples. It is said •»"| ^""^^ 

to occur about once in 2=;oo , *«' i -"^:4'*-t i:,'-* '"^^^^^^rrr^ 




It is more common in multi- ^s^ ' ~ _-_ 

parse and in women approaching Xx^^^^^^^ 

middle life, a point which speaks ^ ' 
in favor of endometritis as a 

cause. Fig. 205.— Deciduoma mahgnum. (Sanger.) a, 

r^-i' - 1 TT* J. J T^' "^^* of decidual cells; 6, another developing; c, 

L/liniCal rllStOry and UiagnO- intermuscular connective tissue; d, muscle-fibres; 

sis.— Fortunately the diagnosis of '' -^— ^^^^ ^i-d. 

this condition does not present difficulties comparable to those which attend 

its etiolog}^ and pathology. 

Inspection shows that the uterus is too large and the fundus too high 
for the period of pregnancy which has been reached, and that the body 
of the uterus is softer than it should be. Ballottement cannot be practised 
and no fetal parts can be outlined. There are, of course, no fetal move- 
ments and no fetal heart-sounds. The disease is essentially one of early 
pregnancy. When it occurs later, only part of the chorion is affected 
and the foetus may survive. This, however, is rare. Sooner or later 
hemorrhages begin. The blood is thinner and lighter in color than in 
placenta praevia but the quantity may be sufficient to cause profound 
anaemia or even death. The bleeding is painless and occurs without 
reference to uterine contractions. Diagnosis should present little difficulty 
to one familiar with the antepartum examination of pregnancy. ]\Iost 
significant of all is the size of the uterus, which is out of all proportion to 
the period of pregnancy. Of course the expulsion of a cvst — even one— 



348 



PATHOLOGY OF PREGXAXCY AND LABOR 



Syr^rnf. 

\ 






*f 



Byncyt. 



settles the matter, but so would the presence of a cystic growth in the 
vagina, since this would be a metastasis from the uterine cavity. 

Fabre has observed the frequent coexistence of albuminuria and the 
vomiting of pregnancy. DeLee has made a similar observation. 

Treatment. — It is best to empty the uterus as soon as the diagnosis is 
made, ^^'e do not know how numerous or how severe future hemorrhages 
may be, and there is always the possibility of the development of the 
dreaded sequel, deciduoma malignum. 

Brusque and heroic measures are 
out of place, however, since the 
uterine wall may have been weakened. 
If the cervix is sufficiently dilated, e.g., 
if an abortion is in progress, the 
uterus should be emptied of its con- 
tents by the method described in con- 
nection with the management of in- 
complete abortion. If not, the vagina 
should be carefully tamponed. This 
experiment not only serves to check 
hemorrhage but also to produce soften- 
ing and dilatation of the cervix. 
^Meanwhile ergot may be given hypo- 
dermatically, since the usual contra- 
indications to its use are absent. The 
curette should be avoided, as there is 
considerable danger of perforation 
in these cases. The attendant should 
remain with his patient until all imme- 
diate danger seems to have passed. 
The hemorrhage may be exceedingly 
free, especially if the patient has 
passed the fourth or fifth month. If 
bleeding continues after the uterus is 
empty the latter should be promptly 
and thoroughly packed. If an anaes- 
thetic is necessary ether or nitrous oxide is to be preferred. 

The patient should be kept under observation for several years with 
reference to the possible development of chorio-epithelioma. 




Fig. 206. — Chorio-epithelioma malignum. 
(Ulesco-Stroganowa.) Syncyt., tissue consist- 
ingof syncytium; £c.,ectoderma cells, or cho- 
rion epithelium; G, giant cells. 



CHORIO-EPITHELIOMA 



In this condition, first recognized by Sanger in 1889, there is a malig- 
nant degeneration of the syncitium and of the cells of Langhans's layer, 
the structures involved in molar pregnancy. Sanger regarded it as a 



sarcoma, but its true nature 



first discovered bv ]\Iarchand in li 



It was he who gave it the name chorio-epithelioma. It takes its origin 



ANOMALIES OF THE FOETUS 



349 



from the placental site and is characterized by a startling rapidity of 
growth and by its tendency to metastatic involvement of distant regions, 
especially the brain and lungs through the medium of the blood-vessels 
(Figs. 206 and 207). 

Xow and then metastases are observed about the vag-ina and vulva and 



after a time these metastases contain blood and villous cysts. 



They are 




Imaj 



Fig. 207. — Sagittal section through the pelvic organs of a patient with chorio-epithelioma malig- 
num. (Marchand.) c, cavity of the uterus; tt, malignant tumors in the body of the uterus; v, bladder; 
o, enlarged oedematous right ovary; ex, varicose tumor beside the ovary; /, fimbriae; ex, cervix, infil- 
trated with blood; r, rectum; tv, tv, tumors in the vagina; u, urethra; s, symphysis pubis; sp, sphincter 
ani muscle; w/, ulceration of the meatus urinarius; ^s, sanguineous tumor between the urethra and the 
pubic arch; ee, corpora cavernosa clitoridis; h, hymen; /c, fraenum clitoridis; Imaj, labium majus; Imin, 
labium minus. 

probably simply transplanted villi, since excision has resulted in their 
complete disappearance without recurrence. 

Etiology. — We know little or nothing of the cause of epithelioma, 
whether in the placenta or elsewhere, but we do know the invasive proper- 
ties of the fetal ectoderm and its tendency to invade the blood-vessels. It 
is not strange that epithelioma of this structure should make rapid 
progress. 



350 PATHOLOGY OF PREGNANCY AND LABOR 

The great predisposing cause is pregnancy. About 50 per cent, of the 
cases follow molar pregnancy, but the latter is not a necessary forerunner. 
Chorio-epithelioma may follow abortion or labor at term. 

Clinical History. — Atypical hemorrhage is the first symptom. In 
perhaps half the cases it follows molar pregnancy, in others labor at term. 
In still others it follows abortion. If curettage is done after an early abor- 
tion, and done properly, hemorrhage promptly ceases. The same thing 
is true if the uterus has been emptied, lege artis, for mole pregnancy. 
Therefore, if irregular bleeding persists in either of these cases or after 
delivery at term, a microscopical examination by a skilled and careful 
pathologist should be made. 

The time at which the symptoms appear is very variable. They may be 
noticed within a few days or not until a few years after delivery. The 
growth has even been made out in the case of mole pregnancy before the 
expulsion of the mole. 

The symptoms are those of an?emia from the hemorrhages, and 
cachexia and sepsis from the malignant growth in the uterus ; pallor, debil- 
ity, progressive emaciation and a foul vaginal discharge. As in pyaemic 
infection the metastases will produce symptoms that vary with tlie location. 
For example, in pulmonary metastasis there may be dyspnoea, bloody 
expectoration, cough, physical signs, sharply localized, etc. 

These symptoms, while typical, are by no means constant. According 
to Williams the appearance of vulvar or vaginal metastases is in more than 
one-half the cases the first evidence of the existence of the growth in utero. 
Strangely enough, these vulvar and vaginal lesions may be present when 
the uterus contains nothing abnormal. 

Treatment. — The treatment for chorio-epithelioma is hysterectomy, 
and in view of the rapid progress of the affection the operation should be 
performed as soon as the diagnosis is established. Cysts of the vagina and 
vulva should be excised. 

Diseases of the Amnion (Hydramnion. Oligo Hydramnion. 
Amniotic Bands. Amnio-Uterine Adhesions) 

hydramnion 

By this term is meant an excessive amount of amniotic fluid. But the 
question is asked at once, " What is an excessive quantity ? " Perhaps two 
litres would be approximately correct, but even this amount, while it may 
be a source of discomfort to one patient, would be quite unnoticed by 
another. Manifestly then, hydramnion, clinically speaking, is applied to a 
condition in which the excess of liquor amnii is sufficient to cause 
symptoms. \\'hat are these symptoms? 

Clinical History. — The subjective symptoms are for the most part 
the result of pressure. Pressure against the diaphragm causes a tor- 
mentmg dyspnoea, pelvic pressure obstructs the return circulation, causing 



ANOMALIES OF THE FCETUS 351 

or aggravating varicose veins and resulting in marked oedema of the feet 
and legs. Finally the intra-uterine pressure which results from the dis- 
tention reflexly excites uterine contractions and these may become quite 
painful. A'ery often the cervical canal becomes obliterated but the thinned 
and paralyzed uterine mtiscle cannot accomplish the dilatation of the 
cervix and the patient's sufferings are indefinitely prolonged. The con- 
dition is similar to that which obtains in the latter weeks of twin- 
pregnancy. 

Palpation gives results that are typical. The observant examiner will 
never fail to note the evidences of an excessive amount of amniotic fluid. 
The abdomen is distended and the fundus at a higher level than usual. 
Palpation of fetal parts is unsatisfactory but ballottement, both external 
and internal, is characteristic and very easy. The foetus is very movable 
and external version can be performed without difficulty. As might be 
expected malpositions and malpresentations are very common, but, owing 
to the small size of the foetus, this fact in itself is not of great clinical 
significance. The fetal heart sounds are feeble or absent. For this there 
are two reasons, the fact that the foetus is usually premature or feeble, 
and the interposition of a large amount of water. 

Of course these symptoms are not always present. And they are more 
easily borne when gradually developed than in the acute cases sometimes 
observed. After all it is not the mere fact of the presence of a large 
quantity of fluid, but the symptoms produced, which determine the neces- 
sity for interference. Patients differ greatly in their tolerance of the 
condition. One is often astonished to see a patient with an enormous 
accumulation of liquor amnii but showing no evidences of discomfort. 

Etiology. — Hydramnion is often associated with some disease or 
deformity of the foetus and its connection with twin-pregnancy is a matter 
of common observation. It has often been regarded as of fetal origin, 
due perhaps to stimulation of the nervous mechanism of the urinary secre- 
tion, as in spina bifida, from the fact that the cord is exposed or to some 
obstruction to the fetal placental circulation, e.g., cardiac disease, knots in 
the cord, etc. It has also been attributed to disturbances of the maternal 
circulation, and to inflammation of the amnion itself. The occurrence of 
hydramnion as a complication of syphilis has already been noted. 

On the whole we know little that is positive about the cause of 
hydramnion ; nor is this to be wondered at. Since we do not as yet know 
the source of the liquor amnii in physiological pregnancy, it is not strange 
that we should find it difficult to account for its production in excess. 

Treatment. — When the symptoms are moderate in degree, the patient 
merely suffering more or less discomfort, palliative measures must suffice. 
If, however, dyspnoea is marked or cardiac embarrassment supervenes, 
labor should be induced. In hydramnion this is an easy matter. The 
canal of the cervix has usually been obliterated and there is already some 
slight dilatation of the os. After the escape of the amniotic fluid, the 



352 PATHOLOGY OF PREGNANCY AND LABOR 

uterus rapidly regains its tone, the muscle becomes thicker, there is a 
rearrangement of its fibres, contraction and retraction go on normally, 
and labor is soon completed, or operative delivery, if necessary, easily 
accomplished. The attendant should not forget that there is a predisposi- 
tion to hemorrhage in these cases. 

OLIGO HYDRAMXIOX 

By this term is meant an abnormally small quantity of amniotic fluid. 
Little Is known as to the cause, though it has been associated by Jaggard 
with absence of the fetal kidneys, imperforate urethra, and various causes 
of retention or non-secretion of urine, and by Ahlfeld with morbid con- 
ditions of the skin, interfering with excretion. Occurring in early preg- 
nancy, it is the cause of malformations and intra-uterine amputations 
already referred to. Later it causes the fetal movements to be felt much 
more plainly since there is no fluid medium to act as a buffer. In some 
cases they are quite painful. When in the latter months the uterus is ver}^ 
closely applied to the fetal surface, the compression may lead to club-foot, 
spinal cur\-ature, wry neck, wrist drop, etc. 

During labor, if the fluid is very much reduced in quantity, the con- 
ditions approximate those which obtain in cases of premature rupture 
of the membranes. The amniotic pouch, so eft'ectual as a dilator, is lacking 
or insuflicient. The uterine contractions are painful and ineft'ectual and 
artificial dilatation of the cervix may be necessar^\ 

A^rXIOTIC BAXDS 

In early pregnancy inflammation of the amnion may result in the 
production of firm adhesions between the amnion and the cutaneous sur- 
face of the foetus and the production of deformities by restriction of 
growth. "' Intra-uterine amputations '' may be thus caused. Such cases 
constitute a fruitful source of " evidence " for those who believe in the 
occurrence of what are called maternal impressions. All that is needed is 
that the mother or some one of her friends shall have heard of some 
human being or animal with one arm or one leg and the evidence is, for a 
certain type of mind, complete. 

Wq have already seen that adhesions between the amnion and the 
uterine wall may delay the first stage of labor. This important matter, so 
often neglected or overlooked, I have already referred to in connection 
with the subject of delayed labor. 



B. THE PATHOLOGY OF LABOR 

CHAPTER XVni 

ANOMALIES OF THE EXPELLENT FORCES 

Abnormal labor, or dystocia, as it is technically called, has been 
variously classified. Perhaps the time-honored three-fold classification of 
the older writers remains the most satisfactory. According to this, we 
divide the many anomalies that must in a general way be the study of the 
obstetrician as follows : 

I. Those which have to do with the expulsive forces. 2. Those which 
are of fetal origin, e.g., structural anomalies of the foetus and the various 
malpositions and malpresentations. 3. Those which are the result of mal- 
formations of the birth canal, e.g., pelvic contraction, pelvic tumors, 
stenoses, etc. 

All this was clearly expressed in the homely and vigorous phraseology 
of our fathers under the heading of anomalies of the powers, the passenger 
and the passages. 

The casuist can pick flaws in this classification. He may say, for 
example, that a malposition is sometimes caused by a uterine anomaly, 
for example, a tumor, and this is quite true. But to this the reply is that 
classification is not an end in itself but rather a means to an end. Too 
much refinement in definition obscures rather than aids. 

Anomalies in the L'terine Forces 

Every practitioner who does much obstetric work soon learns that 
there are many variations from the regular course of normal labor, as I 
have tried to describe in Chapter V^L But not all these variations are to be 
regarded as pathological. Such an attitude leads to a pedantic and meddle- 
some policy that does not subserve the interests of the patient. As a 
general rule, the inexperienced and overanxious observer is more likely 
to discover what he considers abnormalities than is the experienced 
accoucheur. The course of labor may vary within wide limits without 
giving cause for anxiety. Ordinarily, it is only when such variations 
affect, or threaten to afTect, the condition of mother or child that inter- 
ference becomes necessary. 

Irregularities in the force and efifect of the uterine contractions are 
frequent in the early part of the first stage. In some cases irregular pains 
are a source of discomfort for days before the advent of true labor. 
Again, the pains may come at regular intervals, simulating closely those 
of true labor and continuing for several hours, only to die away after a 
time. The cervix will be found more or less dilated but as a rule the 
canal is not completely obliterated. Less commonly the first stage may 
23 353 



354 PATHOLOGY OF PREGNANCY AND LABOR 

drag along for two or three days with httle or no progress, but without 
great suffering or threatened exhaustion. In some cases contractions 
begin in the morning hours and continue until the middle of the day, the 
same process being repeated the next day. 

It is not always possible to tell the cause of delay in these cases. To 
my mind they illustrate a truth that I have long taught, vi^., that there 
is no exact line of demarcation between pregnancy and labor. The 
explanation commonly invoked is that of uterine inertia. This much- 
abused term is too often used as a cloak for lack of skill in diagnosis or 
a euphemism to explain certain facts in connection with the physiolog}" 
of labor of which we know as yet little or nothing. It has more than once 
been my lot to be called to see a supposed case of delayed labor, only to 
find that the pains were not typical of true labor and that while there was 
perhaps some dilatation of the cerv^ix, the canal was not yet fully obliter- 
ated ; in other words, that the patient was not in labor at all. To treat 
such a case actively, perhaps by manual dilatation and forceps or version, 
as is sometimes done, is a disastrous mistake. A severe operation is 
unnecessarily performed and perhaps with very unfortunate results for 
mother or child. The young physician w^ill do well to make sure that labor 
is really in progress before adopting active measures. 

But there is such a thing as uterine inertia, or powerlessness, which is 
what the term really means when used in the obstetrical sense, that 
deserves careful study. This incompetence of the uterus for its task 
may be due to many different factors of widely different kinds. The study 
of the subject is much facilitated by the division of uterine inertia into two 
classes: i. Primary or Essential Inertia. 2. Secondary or Acquired 
Inertia. 

PRIMARY INERTIA 

By primary or essential inertia is meant an inability of the uterine 
muscle to perform its functions during labor, this inability being present 
before labor begins and having nothing to do per se with the various com- 
plications of labor. It is often said to be congenital or hereditary, but 
these terms usually mean only that we do not understand the real cause. 
True primary inertia is very rare indeed. Perhaps the nearest approach 
thereto which can actually be demonstrated is found in the case of certain 
non-rhachitic dwarfs with atrophic skeletal and muscular systems. The 
general practitioner, however, will meet with these cases but rarely. 

It is a matter of every-day experience that stout women of the so-called 
lymphatic temperament often suffer from defective uterine action, but 
just why cannot be stated. 

Congenital or unexplained defects in the uterine muscle or unexplained 
anomalies in uterine innervation we may imas^ine, but cannot explain. 

That there is, however, in certain cases deficient contractile power in 



ANOMALIES OF THE EXPELLENT FORCES 355 

the uterine muscle which manifests itself at the beginning of labor and 
for want of a better name may be called primary, essential, or idiopathic 
weakness, there can be no doubt. Used to describe this condition, the term 
uterine inertia is justifiable. The condition is to be distinguished from 
the so-called uterine inertia by the fact that the uterine contractions are 
frequent and ineiiectual from the start, and by the further fact that no 
pathological condition in mother or child which might account for the 
condition can be found, ^^llatever the cause may be, it exists before 
the beginning of labor. 



SECONDARY INERTIA 

Secondary inertia is not a condition in itself, but the result of some 
other condition. Its causes are multiform and their recognition of great 
importance. \Mien in the course of labor the uterine contractions cease 
or become absent or inefficient there is usually a demonstrable cause which 
can be found and remedied by one who has mastered the principles of 
obstetric diagnosis. This, however, is not always the case. The prac- 
titioner cannot always be blamed because he cannot find the cause of delay. 
There are occasional cases in which the symptoms tell us plainly that it 
is our duty to interfere but in which we are unable with the means now 
at our disposal to determine the cause of delay. 

The more common causes of secondary inertia, or, better, of delayed 
labor, as far as we know them, may be grouped under three heads : Disturb- 
ances of innervation ; mechanical causes ; uterine exhaustion. 

That psychical conditions influence the progress of labor is known to 
all practitioners. That the contractions are often temporarily arrested by 
some powerful emotion, or even by the arrival of the physician, or by the 
presence of meddlesome relatives or friends, is a matter of common obser- 
vation. In these cases the innervation of the uterine muscle is reflexly 
disturbed. 

Again, there is a class of cases in which uterine contraction is reflexly 
inhibited by the influence of pain and fear. Every practitioner soon be- 
comes familiar with this variety. The patient is of the neurotic type, 
or perhaps of that peculiar type which, while well balanced in other 
respects, cannot bear pain well. She cries out at the approach of every 
pain and cannot be quieted even in the intervals. She appears to sufifer 
acutely but makes little or no progress. Cervical dilatation is slow or 
ceases altogether. Position and presentation are normal, the head enters 
the brim easily, and careful exploration reveals no cause for delay. Here 
again the trouble is purely reflex, as is shown by the fact that the adminis- 
tration of chloral or some other hypnotic in sufficient dose promptly effects 
a cure. 

But there are reflex causes of delay that have nothing to do with the 
nervous system. It is well known that a distended bladder often arrests 



356 PATHOLOGY OF PREGNANCY AND LABOR 

the progress of labor. That this delay cannot be altogether mechanical 
in origin is shown by the fact that the distended bladder does not occupy 
the pelvic cavity and, very conclusively, by the further fact that it prevents 
uterine contraction after delivery as well as before. 

The same thing is true of an overloaded bowel, though to a much 
less extent. In this case the cause is partly mechanical, especially if the 
rectum is filled with hardened masses. 

Facts like these are not only interesting, but of the highest practical 
value, since they at once suggest effective measures of treatment. 

Then there is a class of cases in which the obstacle to uterine con- 
traction is plainly and exclusively mechanical. The uterus cannot work 
to advantage on account of some mechanical interference. For example, 
in cases of hydramnion and twin pregnancy, the uterine muscle is so 
thinned and stretched that its contractions are feeble and ineffectual. The 
long first stage in these cases is proverbial. If, however, the membranes 
are ruptured and the uterus permitted to contract upon its contents, the 
contractions improve in force and frequency, and if the delay has not 
already been so great as to exhaust the uterine muscle, the second stage 
is rapidly completed. 

In this class are included cases of pendulous abdomen or marked 
lateral deviation of the fundus to one side (lateroversion). That the 
uterus cannot work to advantage when its long axis is directed too far 
backward, as in pendulous abdomen, or too much to one side, as in latero- 
version, requires no explanation. In the same category would come the 
various malpositions and malpresentations, imusual size of the foetus, 
hydrocephalus, tumors, contracted pelves, etc. All of these are con- 
sidered elsewhere. Uterine malformations and tumors may also constitute 
causes of delay. 

Certain acquired conditions referable to the uterine muscle are some- 
times cited as causes of inertia. Among these are chronic metritis and 
endometritis, and antepartum infection. Bumm believes that the uterine 
muscle may be the subject of a condition analogous to that which is 
observed in lumbago, torticollis, etc. {rheiimatismiis uteri), and has 
observed marked benefit from the use of the salicylates. Tumors may 
interfere with uterine contractions not only mechanically but by replacing 
the muscular structure, as in the case of fibroids, not only mechanically, 
as when the mass directly obstructs the birth canal, but also by replacing 
the muscular structure. 

Rigidity of the Cervix 

Rigidity of the cer^ax is often given as a cause of delayed labor and 
uterine exhaustion. In my opinion true rigidity of the cervix at term is 
very rare. Too often the term is used to mask ignorance of obstetric 
diagnosis, or, honestly enough, because of unfamiliarity with the pathology 



ANOMALIES OF THE EXPELLExNT FORCES 357 

of labor. One almost wishes that such terms as uterine inertia, and rigidity 
of the cervix, might be banished from the text-books. When the full 
term cervix refuses to dilate during labor, it is usually because the dilating 
force fails, or is not properly applied. This is shown by the fact that the 
cer^-ix in these cases almost always yields to manual dilatation, even though 
no great force is used. 

\\'hen the cervix does not dilate a careful examination will usually 
disclose the cause. It may prove to be an unsuspected contraction of the 
pelvis or some malposition or malpresentation. Premature rupture of 
the membranes is a common cause. I have often found it to be a posterior 
position of the occiput. I recall a case which I was once asked to see 
and which had previously been seen by a well-known gynaecologist. The 
latter had made a diagnosis of rigidity of the cervix. Examination 
revealed a posterior position of the occiput. Thus the non-dilatation of 
the cervix was readily explained and the remedy suggested. 

The cen.-ix, Hke the other soft parts, is somewhat more resistant in 
primiparae of middle age than in younger women, but even in these cases 
manual dilatation can usually be accomplished without trouble. 

It must be admitted, however, and this is an important clinical fact 
commonly overlooked, that the cervix is sometimes very resistant in cases 
of premature labor. In these cases it may be impossible to secure 
immediate dilatation by the employment of any force that is justifiable, 
even after the cervical canal has been obliterated. 

In certain cases the cause of delay and of non-dilatation is to be 
found in the fact that the amnion is adherent to the uterine wall and that 
for this reason the presenting segment of the amniotic sac is prevented 
from entering the cervix. The difficulty may be speedily removed by 
separating the membranes from the uterine wall with the finger, 

A short umbilical cord may also prevent the descent of the foetus. 
The delay is easily accounted for after delivery, but during labor it is 
hardly possible to make a positive diagnosis. 

At the last analysis, however, secondary inertia is usually nothing 
more nor less than uterine exhaustion. Like other muscles, the muscle of 
the uterus may become so exhausted by long and hard work that it 
responds but feebly to ordinary stimuli. If no rest is afiforded, it may 
finally fail to respond to any stimuli. These conditions are called, respec- 
tively, incomplete and complete uterine inertia. The fruitless efforts of 
the uterus to overcome some mechanical condition or obstacle are at the 
root of the trouble. It is not that the uterus is too weak, but that the 
obstacle is too strong. 

The cause is almost always some one of the conditions already men- 
tioned. Among these are all kinds of pelvic deformity, all malpositions 
and malpresentations, tumors blocking the pelvic cavity, etc. In prema- 
ture rupture of the membranes the uncovered fetal head, a poor dilator 
of the cervix, is substituted for nature's ideal dilator, the " bag of waters/' 



358 PATHOLOGY OF PREGXAXCY AND LABOR 



n 



Here, unaided, nature may be unable to accomplish the task, especially if 
the head is large. 

In my experience the most frequent factors in CA'ery-day practice, 
and those most commonly overlooked, are posterior positions of the 
occiput and unusual size of the fetal head. Inertia uteri is not as common 
as formerly and marked degrees seldom occur in the practice of those 
who practise modern methods. 

Hofmeier has recently maintained that certain cases of apparent 
inertia following difficult labor are not due to exhaustion, but to the fact 
that the uterus reaches its limit of retraction, and thus of its propelling 
force, long before labor is complete. However this may be, the symptoms 
and the indications for treatment are the same. 

In the second stage of labor the abdominal muscles come into play. 
Inertia of these muscles may be due to the exhaustion resulting from a 
long first or second stage, to general muscular weakness, to exhausting dis- 
ease, or to overdistention of the abdomen, as in the case of twin-pregnancy 
or hydramnion. Again there may be a mechanical cause, as diastasis recti, 
or pendulous abdomen. All the malpositions may act as causes. A short 
lunbilical cord is an occasional source of delay. Contraction at the pelvic 
outlet is often overlooked by those who do not practise pelvimetry. Fear 
of pain leads some patients to resist bearing-down efforts. A distended 
bladder may delay labor in the second stage, although its influence is less 
powerful than in the first. The improper or excessive use of narcotics 
or anaesthetics may have the same effect. The average prolongation of 
the second stage in the " twilight sleep " is one hour. Late primiparity is a 
factor. 

Clinical History. — In primary inertia the contractions are weak and 
infrequent from the beginning of labor. The patient may belong to one 
of the types already mentioned as illustrating the condition. Primar}' 
inertia, however, is not necessarily a part of general muscular weakness, 
since it may be present in strong and apparently healthy women, whereas 
every physician knows that weak and anaemic women often have powerful 
uterine contractions. 

In secondary inertia the symptoms indicative of the condition do not 
appear until after some hours of good labor pains. The contractions which 
have hitherto been strong become weaker. In some cases the contraction 
begins normally but is of very short duration. The uterine muscle, unequal 
to its task, relaxes in a few seconds. The hand which has become accus- 
tomed to palpating the uterus during the contractions of normal labor 
(and the young physician should not neglect his opportunities in this 
respect) at once recognizes the dift'erence. 

At the same time examination shows that the head is not descending, 
and that dilatation of the cervix is not progressing. There is usually 
a marked change in the psychical condition of the patient. It is my 
observation that intelligent women, especially those who have had children 



AXO:\IALIES OF THE EXPELLENT FORCES 359 

before, often recognize the condition themselves. I am in the habit of 
paying considerable attention to the statements of such patients. This 
matter is further discussed in connection with the forceps operation. 

The character of the contractions that precede uterine exhaustion at 
once attracts the attention of the experienced accoucheur. They are 
accompanied by sulfering that is severe and at times intolerable. In nor- 
mal labor the head descends and recedes alternately and while the pains 
are severe there are frequent intervals of relief. When, however, progress 
ceases and the uterine contractions continue, the results of long-continued 
reciprocal pressure between the fetal head and the adjacent structures 
are shown in the intolerable severity of the " pains " and in the fact that 
the patient does not experience complete relief even in the intervals. 

If relief is not afforded the contractions gradually grow weaker and 
perhaps cease altogether. The hand placed over the uterus recognizes 
the change at once. The fetal parts are palpable even between the con- 
tractions, and through the relaxed uterine wall the fetal heart sounds may 
be heard, not only between the contractions, but during the contractions 
themselves. After a time the uterine muscle ceases to respond to any 
reflex irritation and even massage of the fundus has no effect. The abdom- 
inal muscles have also become inert and incapable of further work and 
coils of intestine can be traced between abdomen and uterus. The vagina 
becomes hot and dry, and after a time the venous congestion below the 
" circle of contact " of the presenting part leads to capillary rupture, which 
is signalized by a brownish-red discharge from the vagina. This dis- 
charge was considered by the older writers to be a signal for interference. 
AA'e know now that it is a sign that interference has been too long delayed. 
The temperature is sub febrile, one hundred or thereabouts, though it may 
be normal, and there is a steady rise in the pulse-rate. 

Thanks to the progress of obstetric science this melancholy picture 
has been all but banished from sick-room and hospital. He who would 
allow one of his patients to reach this stage should adopt some other 
calling than that of the obstetrician. 

Treatment. — The treatment of delayed labor is a comprehensive sub- 
ject, involving as it does the treatment, preventive and curative, of most 
of the complications of labor. Since, however, the evidences of uterine 
exhaustion and the indications for interference are to a large extent the 
same in all cases, and in particular, since we may not know the cause of 
delay, it may be well to consider here certain general principles of treat- 
ment that are applicable to all cases alike. 

In the class of cases mentioned above, in which irregular pains precede 
the development of active labor, I have sometimes found the cause to be 
an overloaded intestine. In this case the administration of a cathartic 
at once relieves the symptoms. Castor oil should not be given unless the 
attendant is satisfied that the patient is at term and that the beginning 
of labor is desirable. If he has reason to believe that this is not the case 



360 PATHOLOGY OF PREGNANCY AND LABOR 

a saline cathartic and an enema of olive oil are to be preferred. A simple 
anodyne, e.g., a full dose of codeine at bed-time, often works wonders 
by securing the patient a good night's sleep. 

In some cases the patient will have regular contractions attended by 
considerable pain and continuing for several hours, only to cease and 
reappear the following day. I have found this condition so common, espe- 
cially in hospital practice, that I have ceased to regard it as pathological. 
It is in some cases a kind of prelude to labor. Examination shows no 
abnormality and active treatment does more harm than good. 

But suppose that labor has really begun, as shown by continuous and 
regularly recurring pains, and by complete obliteration of the cervical 
canal, but does not progress as rapidly as one would like. What then ? 

In the first place it is of the utmost importance that the beginner should 
at the outset rid his mind of the idea that a slow labor or even a delayed 
labor necessarily indicates active treatment or surgical interference. The 
thinking man soon learns to recognize that the problem is not one of 
hours or even days but of the condition of mother or child. I cannot 
agree, however, with those who would postpone interference until unmis- 
takable signs of exhaustion are present. To wait until this time may be 
to wait until irremediable harm has been done. It should be the aim 
of the obstetrician to learn how to recognize in advance conditions that 
are certain to require interference, and to anticipate the symptoms of 
exhaustion. This subject is discussed in connection with the forceps 
operation and need not be considered here. 

It is highly important that the beginner should know what not to do. 
He should not subject the patient to internal examinations, frequently 
repeated, and continued over a long interval. It is in just these cases that 
such examinations are often insufficient even for the trained specialist, and 
as pointed out in the chapter on normal labor they may do incalculable 
harm. If no immediate danger to mother or child is apparent it is better 
for the attendant to content himself with such general measures as have 
been already described, especially those which conduce to the relief of 
suffering, and to wait patiently upon the eftorts of nature, meanwhile, 
however, watching the patient carefully, not absenting himself too long, 
and occasionally auscultating the fetal heart. 

Whenever the attendant becomes satisfied that all is not as it should 
be, he should proceed calmly and deliberately to find the cause. An enema 
should be given and the bladder should be emptied with care. The patient 
is now anaesthetized and brought to the edge of the bed or table and 
examined, the half-hand being used if necessary. It is better to use a 
table, since an operation of some kind may be required. ]\Ieanwhile every 
preparation for an operation should be made as described elsewhere 
(p. 541). In this way if an operation is deemed necessary it may be per- 
formed without delay and the danger of repeated anaesthesias and addi- 
tional manipulation is avoided. Even though no serious operative 



ANOMALIES OF THE EXPELLENT FORCES 361 

procedure is demanded, it will often be found that the temporary relief 
from suft'ering and the relaxation resulting from the anaesthesia, aided 
perhaps by some manipulation such as the rupture of the membranes or a 
partial manual dilatation, will suffice to bring labor to a happy termination. 

If the examination reveals, as it may, some definite complication which 
is plainly the cause of delay, e.g., an unsuspected contraction of the pelvis, 
some malpresentation, or perhaps unusual size of the fetal head (the latter 
is difficult to determine), it is to be promptly treated by the rules laid down 
elsewhere. 

If the case is of the neurotic type, in which there is reflex inhibition of 
uterine contractions through nervousness and fear, the happiest results 
are often obtained by the exhibition of chloral in fifteen-grain doses. More 
than one dose is seldom required. Under the influence of this drug the 
pain becomes less severe, the patient dozes in the intervals between con- 
tractions, and dilatation often proceeds with miexpected rapidity. Mor- 
phine, narcophen, or pantopon, hypodermically, may be given if preferred, 
or morphine and hyoscine in combination. The inexperienced worker, 
however, is warned against the endeavor to narcotize the patient during 
the whole course of labor. This involves considerable risk to the child, 
^luch may be accomplished during the second stage by giving a few drops 
of ether with each pain. 

A partial manual dilatation under anaesthesia is often of the greatest 
service in these cases. Of course this should not be undertaken unless 
the cervical canal has been obliterated and the cervix is soft and distensible. 
If, after dilatation, the membranes are ruptured and the amniotic fluid 
allowed to escape, the uterus contracts upon the foetus and the reflex 
impulse to '' bear down " soon becomes irresistible. 

In afl cases, however, the attendant should first endeavor to satisfy 
himself that he is not overlooking some mechanical obstruction in the 
way of pelvic contraction, posterior occiput, etc. 

If the case is one of premature rupture of the membranes, a long and 
tedious labor may usually be expected. The uncovered fetal, head is a 
poor dilator of the cervix. The danger of infection is increased, since 
there is a tendency to decomposition of the retained liquor amnii, and, if 
operative interference becomes necessary, there is an increased likelihood 
of cervical laceration. The prolongation of the labor and the fact that 
the uterus presses directly upon the foetus, the protective fluid medium 
being absent, enhance the danger to the child. All these dangers are best 
avoided by the introduction of a de Ribes bag within the cervix. In this 
way nature's method of hydrostatic dilatation is closely imitated, and the 
outflow of the retained amniotic fluid in part at least prevented. 

In these cases the fetal heart should be carefully watched, and the 
second stage not allowed tO' linger too long. 

But the difficulty may be an excess of amniotic fluid, as in twin labor 
or hydramnion. Here the remedy is the artificial rupture of the mem- 



362 PATHOLOGY OF PREGXAXCY AND LABOR 

branes. This accomplished, the thinned and distended uterine wall regains 
its tonicity and delivery occurs speedily or is easily accomplished by the 
forceps. 

In many other cases, too, all that is needed is the artificial rupture of 
the membranes. As Bumm has observed, this is especially apt to be 
effectual in multiparae with lax and atrophied abdominal and uterine walls. 
But it is a measure which must be employed with discrimination and judg- 
ment. The subject is discussed in the chapter on the management of 
normal labor. 

Pituitrin. — In pituitrin, the extract of the pituitary gland, we now 
have the most eft'ectual method of stimulating uterine contraction during 
labor. L^nlike ergot, the use of which has often proved disastrous, it does 
not cause tonic and continuous contraction. The contractions, w^hile 
much increased in force and frequency, are, like those of normal labor, 
intermittent and succeeded by intervals of repose. The speed and cer- 
tainty of its action are often remarkable. I have seen a delayed second 
stage, which promised to require the forceps, terminated in five or ten 
minutes, and this without the slightest untoward incident. 

It is apparent that the use of so powerful an agent as pituitrin must 
be attended by certain dangers and that certain precautions are necessary. 
As a rule, it should not be employed during the first stage, though occa- 
sional exceptions may be allowed to the experienced operator. Its use 
in the presence of a rigid or but slightly dilated cervix, in pelvic contrac- 
tion, or in any case of mechanical obstruction, might, and indeed has, 
resulted in rupture of the uterus. It is also reasonable to suppose that 
under these circumstances the danger to the foetus would be greatly 
increased, and this has been shown to be the case. 

Pituitrin markedly increases the blood-pressure and w^ould therefore 
seem to be contra-indicated in cardiac, renal, or eclamptic conditions. I am 
not satisfied that this is always true, since unfavorable by-eft'ects may 
always be modified by the use of an anaesthetic. 

The chief field for pituitrin is in delay in the second stage of labor. 
Here it is an agent of great value and often renders the forceps operation 
unnecessary. This is especially desirable in the case of the physician 
who is without assistance and in surroundings that render careful and asep- 
tic work difficult or impossible. Under these circumstances the tedium and 
uncertainty of a delayed second stage are speedily terminated and the 
scene changes in a way to reward physician and patient alike. This is 
especially true of delayed second stage. 

The physician should not forget that the contractions evoked by this 
agent are often prolonged and powerful. He should watch the fetal heart 
and should guard against too rapid expulsion with accompanying lacera- 
tion. If the contractions become too violent they may be promptly con- 
trolled by the administration of an anaesthetic, which should always be at 
hand when one administers pituitrin. Indeed, one of the best methods 



ANOMALIES OF THE EXPELLEXT FORCES 363 

of painlessly completing a delayed second stage is to give pituitrin and 
control its administration by minimal doses of chloroform or ether. It 
is necessary that the attendant should secure a reliable preparation. I 
have found that of Burroughs & Wellcome very satisfactory. 

It is important to remember that the very property of pituitrin which 
renders it so useful in the second stage of labor makes it of less value in 
the treatment of hemorrhage. Pituitrin causes alternate contraction and 
relaxation of the uterus, and bleeding may occur during the periods of 
relaxation. Moreover the powerful contractions are, according to some 
writers, followed by a period of uterine atony, which is in itself a cause 
of hemorrhage. Some practitioners and writers seem to have conceived 
the idea that after pituitrin has been administered security against hemor- 
rhage has been attained. This is a grave error. In all doubtful cases ergot 
should also be given. The permanent tonic contraction which it causes 
is exactly what is needed in these cases and we have as yet no drug which 
can take its place. 

Experience shows that pituitrin has little or no effect in bringing on 
labor. Attempts to induce labor with this agent have been failures. It is, 
however, very valuable as an aid to the process of induction. In this 
operation, by whatever method performed, success is not always brilliant. 
After the cervix has become dilated to the extent of admitting perhaps 
two fingers, the contractions may cease and renewed efforts prove unsuc- 
cessful, leaving the physician in a most embarrassing position. Here 
pituitrin is most useful in completing the process. Of course, the attendant 
should endeavor to satisfy himself that noi contra-indication is present. 
According to Rongy and Arluck bad results are not observed here because 
the uterine wall is thick and the contractions evoked are not of violent 
character. Then, too, the foetus is often small. 

Ergot is seldom or never used nowadays until the placenta has been 
expelled or its expulsion within a few minutes seems certain. Its tendency 
to produce permanent tonic contraction, thus endangering the life of the 
foetus or causing retention of the placenta, has long been well known. 
For uterine inertia during the third stage it is, as we have seen, an incom- 
parable remedy. It is also very useful in the treatment of abortion, in 
which hemorrhage is an ever-present danger, and the preservation of 
fetal life does not enter into the question. 

Quinine in large doses is warmly advocated by some as a remedy for 
the inertia of the second stage. It has seemed to me to be more successful 
in malarial subjects or in malarial regions. At all events it is sometimes 
successful and at other times fails completely. A large dose, fifteen or 
twenty grains, is necessary. In the absence of pituitrin and under the 
above circumstances it is well worth a trial. 

Strychnia is sometimes given during the latter weeks of pregnancy with 
the idea of stimulating the uterine muscle to good contractions during 
labor. Its efiicacy is problematical. 



364 



PATHOLOGY OF PREGNANCY AND LABOR 



Expressio foetus, after Kristeller's method, is sufficiently illustrated in 
Fig. 208. It is sometimes effectual when the head is on the pelvic floor. 
At other times it is not successful. One can only tell by trying. This 
method is of great value in the case of premature children and of twins, 
especially of the second twin. In these cases it may be used even when 
the head is high, provided that the cervix is fully dilated. It is of little 
or no value when the foetus is large. 

Posture. — ]\Iuch complicated advice of doubtful value has been given 
upon this subject. Experience has taught me that there are two or three 
points of special value to the practitioner. As a general thing, it is better 
that the patient should be up and about during the first stage. The 




Fig. 208. — Kristeller's expression of foetus. (DeLee, Y/. B. Saunders Co.) 



friction of the abdominal walls against the uterus is said to provoke con- 
tractions, and gravity may have some effect. jMoreover, nature and 
experience alike teach that this attitude is the natural one. If, however, 
the patient is weak or exhausted from loss of sleep or other causes, it is 
better for her to remain quietly in bed, and perhaps to receive some 
anodyne. 

In the second stage the contractions may be stimulated by having the 
patient turn upon the side opposite to that toward which the fundus is 
directed. This causes the fundus to approximate the median line and 
brings the head directly into the middle of the pelvis. I have often 
witnessed the efficacy of this manoeuvre. 



ANOMALIES OF THE EXPELLENT FORCES 365 



Excessive Uterine Retraction. The Ring of Bandl 

As we have already seen, the uterus retracts during labor, drawing 
the cer^'ix up over the head, not pushing the head down through the cervix. 
AMien for some reason, e.g., pelvic contraction, or some malposition or 
malpresentation, this cannot be accomplished, the continuance of uterine 
retraction causes the lower uterine segment to become dangerously thinned 
and stretched while the corpus uteri becomes correspondingly shorter and 
thicker. At the junction of the corpus with the lower segment is felt 
a muscular ridge not discernible in normal labor. The more the lower 
segment becomes stretched the higher this ridge is above the symphysis. 

The ridge is known as the ring of Bandl, from the man who first 
recognized its nature and taught its significance. AVhen it can be plainly 
felt above the symphysis, it may be assumed that there is some obstruction 
to the progress of labor, and of course the higher it ascends, the greater 
the urgency of the case. Strictly speaking, it is not a ring but is felt as a 
ridge extending somewhat obliquely across the lower abdomen above the 
symphysis. It often occurs while the membranes are still intact. It is 
to be regarded as the result of long-continued but fruitless effort on the 
Dart of the uterus to overcome some obstruction or obstacle. 

^lany students regard the formation of the ring of Bandl as an obscure 
phenomenon of little practical interest. This is a great mistake. When- 
ever the ring is found well marked above the symphysis the danger of 
rupture of the uterus should be borne in mind, and treatment should be 
promptly instituted. 

Tetanic Contraction of the Uterus 

Safety to the foetus and some degree of relief for the mother are 
msured by the fact that in normal labor an interval of rest follows every 
uterine contraction. Xow and then, fortunately not often, the uterus 
becomes tonically contracted, i.e., the intervals are absent, and it may 
be a long time, even hours, before relaxation occurs. This tonic con- 
traction is most often observed as the result of ergot, though it may 
occur as the result of irritation from repeated unsuccessful attempts at 
delivery, or when the foetus has long pressed against the uterine wall, as in 
neglected transverse presentation, or in premature rupture of the mem- 
brane. It is to be distinguished from retraction by the fact that the ring 
of Bandl is not to be felt. 

This tonic contraction, however, does not always involve the whole 
uterus. It may involve a circular segment of the uterine wall at any point. 
It is then called a constriction ring and is most common at the external 
or internal os. In the first stage it involves the external os and is probably 
accountable for most of the cases of so-called rigid cervix. In the third 
stage it is represented by the well-known hour-glass contraction, which 



366 PATHOLOGY OF PREGXAXCY AND LABOR 

was so often the result of the ill-timed use of ergot, but may result from 
premature and unskilful efforts at placental expression. 

In this condition a constricting ring separating the upper and lower 
uterine segments causes the latter to assume the shape of an inverted 
funnel, and the inexperienced accoucheur may even think he has passed 
his hand into the uterine cavity when in fact he has only entered the 
distended cervix and lower segment. 

The treatment of the various forms of abnormal contraction and 
retraction of the uterus during labor is discussed in connection w4th ver- 
sion, hour-glass contraction, etc. In a general way it may be said to be the 
administration of an anaesthetic and the performance of whatever opera- 
tion is indicated. In certain cases of annular constriction, e.g., in hour-glass 
contraction, or when the cer^-ix contracts about the neck and imprisons the 
after-coming head of a dead child, it may be only necessary to wait until 
natural relaxation occurs. 

Precipitate Labor 

]\Iuch less coiTLinon than delayed labor is precipitate labor. In this 
form a veritable storm of powerful contractions suffices to propel the foetus 
through the pelvic canal in an incredibly short time. So powerful and 
irresistible, indeed, are the muscular contractions of the second stage that 
child. f?eces and urine may be expelled at the same time. There is hardly 
any interval between contractions, and the patient becomes breathless and 
cyanotic from the constant straining and " bearing down.'" The clinical 
picture is characteristic and unmistakable. 

This is true " precipitate labor."" The cause is not well understood but 
is probably some unexplained anomaly of uterine innervation. L'nder the 
same head are usually included many cases in Avhich the chief feature of 
labor is its rapidity, though the character of the contractions is less dis- 
tinctive. In this category belong most of the "' street births." Rapid 
labor is much more common in multipar^e. Xoav and then a patient will 
be awakened in the middle of the night by the rupture of the membranes 
and two or three '' pains "' will suffice to complete labor. It is not safe, 
however, to conclude that it never occurs in primipar^e. 

Rapid labor is favored by multiparity. by a lax condition of the soft 
parts, and by small size of the child. It does not seem to depend to any 
great extent upon general muscular development. ]\Iany anaemic and 
apparently delicate women have rapid and easy labors. The common idea 
that a roomy pelvis causes rapid labor has little foundation. In primipar?e 
the head has passed the pelvic brim and descended into the cavity lono; 
before the beginning of labor. 

Rapid labor is not always an advantage to the patient. Syncope 
may follow the sudden diminution of the intra-abdominal pressure, and 
the sudden emptying of the uterus predisposes to hemorrhage. But these 



ANOMALIES OF THE EXPELLENT FORCES 367 

dangers are not usually very serious. ]\Iore real is the danger of laceration 
of the soft parts, since there is no time for the slow and gradual distention 
so necessary to their preservation from injury. 

It should not be forgotten that in these cases there is an increased 
risk of infection. Long ago my attention was drawn to this fact in the 
course of out-patient maternity practice. The reason is plain. The child 
is usually born in the absence of a physician or competent nurse, and all 
manipulations are made by unskilled and non-disinfected hands. There 
is an important lesson here for physicians who are called to such cases or 
who happen to be present. There is usually no great occasion for haste 
and. in the absence of hemorrhage or fetal asphyxia, full time should be 
taken for the necessary aseptic precautions. 

Treatment. — For the condition itself the treatment par excellence is 
the administration of an anaesthetic. The patient should be turned upon 
her side in order to weaken the force of the abdominal contractions, and 
the too rapid exit of the head prevented by the measures described and 
illustrated in connection with the subject of the prevention of perineal 
lacerations. Special care should be taken to guard against infection and 
hemorrhasfe. 



CHAPTER XIX 

MALPOSITIONS AND MALPRESENTATIONS OF THE 

FCETUS 

Ix normal labor nature provides that the fetal head shall present by 
its smallest diameter, the suboccipito-bregmatic. In studying the mechan- 
ism of labor we have seen that under favorable conditions the well-flexed 
head enters the pelvis with the occiput obliquely anterior, and that with 
the progress of labor the occiput rotates forward, until during the stage 
of expulsion it is found directly under the pubic arch. It is only in this 
way that the smallest diameter is made to present at the superior strait and 
at the outlet. All cases in which this diameter does not so present are 
theoretically abnormal, and often, though not always, lead to delay in 
labor and require the assistance of art. 

All cephalic malpresentations are attended by undue extension of the 
head and consequently by an increase in the diameter of engagement. For 
example, in occiput posterior cases the occipito-frontal or suboccipito- 
frontal diameter is substituted for the suboccipito-bregmatic, and in face 
and brow presentations still other and longer diameters are substituted. 
All this is shown in the accompanying figures. The Germans ver}- appro- 
priately call these the Deflexionslagen (extension positions). 

A conception of the important fact that all these malpresentations 
simply represent different degrees of extension does much to simplify 
the subject. ]\Iy experience has taught me that those who try to master 
each subject separately end by mastering none. 

Of all abnormalities of vertex presentation by far the most common 
and, for that reason, the most important, is the posterior rotation of the 
occiput. This complication is one of the most common causes of delayed 
labor, and its non-recognition may be followed by disastrous consequences. 
In my experience the most common condition which the obstetric con- 
sultant is called upon to treat is unrecognized posterior position of the 
occiput. And yet the subject in its essentials is simple enough, and 
opportunities for clinical observation are frequent. Every one who intends 
to make obstetrics a part of his work is in duty bound to give the matter 
careful attention. 

Etiology. — Why does the occiput fail to rotate forward? The subject 
is somewhat obscure but it seems plain that a posterior occiput is usually 
associated with deficient flexion, and we know that the latter is usually the 
result of disproportion In size between the head and the pelvis. 

Personally, I am Inclined to believe that the size of the fetal head Is an 
Important factor, since clinical experience has taught me that in a large 
368 



MALPOSITIONS AND MALPRESENTATIONS 369 

proportion of the cases, in whicli the occiput is posterior and in which 
labor is so long delayed that interference becomes necessary, the fetal 
head is of more than average size. It is reasonable to suppose that a 
moderate contraction of the pelvic brim would have the same effect in the 
case of a head of normal size. Then, too, a small, e.g., a premature, head 
may enter the brim and traverse the birth canal in almost any position. 
These cases of course offer little or no difficulty and the complication is 
nominal rather than real. 

Among other causes that have been suggested are conditions involving 
a faulty deviation of the uterine axis, e.g., extreme latero-version, pendu- 
lous abdomen, etc., all of which may modify the position of the head at 
the brim, uterine or pelvic tumors that may mechanically prevent rotation, 
prolapse of hand or arm in front of the occiput, etc. 

It is obvious that inefficient pains and a lax pelvic floor may act as 
contributing causes, i.e., may help to prevent the forward rotation of 
an occiput already posterior. 

Frequency. — Occiput posterior cases are much more common than is 
usually supposed. This, I believe, is the experience of all those who, with 
out-door maternity services at their command, have given careful attention 
to the antepartimi examination. The right posterior position is especially 
frequent, occurring in perhaps 30 per cent, of all cases. The left posterior 
position is much less frequent, though by no means an obstetric curiosity, 
as is sometimes asserted. I have met with it many times and believe that 
it is frequently overlooked. Of course, these estimates apply only to 
patients not yet in labor, and in the majority of cases rotation occurs 
during labor. Nevertheless, the proportion of cases in which anterior 
rotation is delayed long enough to cause symptoms or to require treatment 
is considerable. It has been estimated at 10 per cent. My own experience 
leads me to believe that this estimate is too low. 

Mechanism and Causes of Delay. — After all, what concerns us here 
is not the original cause of posterior positions, but the reason for the 
delay in labor. 

The delay in the first stage is easily accounted for. We have already 
seen that there is usually a disproportion in size between the head and the 
pelvis. Let us suppose that an over-large head oscillates above the pelvic 
brim for a time and then settles down with the occiput posterior. Here 
the long biparietal diameter of the head is opposed to the short sacro- 
cotyloid diameter of the pelvis ; just the opposite of what should be the 
case. This is shown in Figs. 209 and 210. In some cases the disproportion 
prevents the engagement of the head, the cervix dilates slowly and 
incompletely, and the progress of labor is arrested with the head still 
above the brim. 

Here we have a very interesting illustration of the fact that a knowl- 
edge of the mechanism of labor is essential to any correct theory of treat- 
ment. It is obvious that when the head is floating above the brim and its 
24 



370 



PATHOLOGY OF PREGNANCY AND LABOR 



descent is hindered by a distinct disproportion between the presenting 
diameter and the segment of the brim through which it must pass, if it 
passes at all, the use of the forceps is not indicated. The effort to deliver 
would be, and indeed many times has been, simply the setting of force 
against force with slight chance of success and large probability of disaster. 



Fig. 



Fig. 210. 





Fig. 209. — Head presenting at brim; occiput behind; biparietal diameter lying behind oblique diam.eter 
of pelvis. (Herman's Difficult Labor, Wm. Wood & Co.) 

Fig. 210. — Head presenting at brim; occiput in front; biparietal diameter lying in oblique diameter 
of pelvis. (Herman's Difficult Labor, Wm. Wood & Co.) 

Aluch more commonly the head passes the brim and enters the cavity 
of the pelvis. The mechanism by which the head is brought to the floor 
of the pelvis is the same as that which obtains in anterior positions, except, 
of course, that the occiput is obliged to rotate around an arc of 135 degrees, 
three times as far as in anterior positions. Nature is usually equal to 

the task but in a considerable proportion of 
cases anterior rotation does not occur. Just 
why is a matter of dispute. To my mind the 
large size of the head is still an important fac- 
tor, as I have found that in most of my opera- 
tive cases the head was large. It certainly 
demands a greater effort on the part of the 
natural forces to flex and rotate a large head 
than a small one. 

Sometimes these efforts succeed in rotating 
the head to a transverse position and nO' 
farther. In a small proportion of cases, per- 
haps 3 per cent., the occiput rotates into the 
hollow of the sacrum. 

In the latter case the mechanism of expul- 
sion is a complete reversal of that obtaining 
in anterior positions. The occiput, which remains 
posterior, causes the peritoneum to bulge and the head continues to de- 
scend until the brow appears under the pubic arch. The head is now born 
by a movement of extension, the forehead, nose, etc., successively appear- 
ing, sometimes to the great surprise of the careless observer. 

It is easy to see by reference to Fig. 211 that the delay in the expulsive 




Fig. 211. — Showing mode of 
deliver^' when occiput does not 
rotate forward. (Herman's Diffi- 
cult Labor, Wm.Wood & Co.) 



MALPOSITIONS AND MALPRESENTATIONS 371 

stage is due to the fact that the subocciplto- frontal diameter is substituted 
for the shorter suboccipito-bregmatic. 

A'ariations from this typical mechanism sometimes occur. In some 
cases the brow is born first, the root of the nose impinging upon the 
symphysis. The occiput is then pushed through the vulva by a movement 
of flexion, which is often made with a sudden jerk and markedly endangers 
the perineum. The diameter of engagement is the occipito-frontal. 

This mechanism indicates, indeed it is dependent upon, incomplete 
flexion and approaches somewhat the mechanism of brow presentation. 
The German writers give these cases a class by themselves, " top-head " 
presentation ( Vordcrhaiiptslagc) , but English and American writers have 
not thought it worth while further to complicate the matter. 

Thus we need not wonder that the perineum is subjected to a severe 
strain and that lacerations are common, though I have not found them 
as frequent or as severe as is commonly asserted. Perhaps this is due to 
the fact that formerly the most difficult cases, i.e., those in which the fetal 
head was over-large, were not rotated anteriorly by the forceps. If, how- 
ever, the operator, not recognizing the cause of delay, undertakes to deliver 
by force, severe lacerations, even those of the third degree, are by no means 
uncommon. 

Diagnosis and Clinical History. — In the first stage external examina- 
tion is of the greatest possible value. The methods are given in the 
chapter on the antepartum examination. When we recall the fact that 
the R. O. P. position is next in frequency to the L. O. A., and that it occurs 
in 30 per cent, of all cases, it becomes apparent that every man has abun- 
dant opportunity to perfect himself in this method of diagnosis and that 
neglect in this respect is inexcusable. If there is no unusual thickness of 
the abdominal wall the task is easy. 

Hence the following rule : In all cases in which the fetal back is found 
upon the right side the probability of a right posterior position should be 
borne in mind, especially if there are evidences of delayed labor. In the 
R. O. A. position the fetal back is near the median line and the fetal heart- 
sounds are heard near that line, nearer even than in the L. O. A. position. 
It is evident that the greater the distance of these from the median line, 
the greater is the probability of a posterior position. In well-marked cases 
the back may be palpated and the fetal heart-sounds best heard far around 
in the flank. Whenever the physician has an opportunity to examine his 
patient before labor, he should not fail to seek for evidences of a posterior 
position. At this time he can make it out at his leisure and more easily 
than when the patient is in labor. Thus will he be better prepared to 
determine the causes of delay when labor has really begun. 

In left posterior positions the diagnosis is the same, mutatis mutandis, 
as in right posterior — but we must not forget thai in left anterior positions 
the back is palpated and the maximum intensity of the fetal heart-sounds 
found at a greater distance from the median line than in the right anterior. 



372 PATHOLOGY OF PREGXA^XY AND LABOR 

In no instance are the advantages of external examination better 
exemplified. 

With the head above the brim, internal examination will require per- 
haps the introduction of the half hand or even the whole hand. This 
in turn requires an anaesthetic, increases the risk of sepsis, and is not 
justifiable unless the symptoms are such as to demand intervention. In 
that case the internal examination is used to confirm the external and, 
as the usual treatment is version, the latter may be performed without 
the withdrawal of the hand. 

When the head has reached the floor of the pelvis, or is well down in 
the cavity, external examination gives less satisfactory results, and we 
are obliged to rely chiefly upon the results of internal examination. The 
large soft anterior fontanelle is felt obliquely anterior, i.e., in one or the 
other iliac fossa, usually the right, while the small fontanelle is posterior 
and difficult to reach ; just the opposite of what obtains in anterior 
positions. 

The diagnosis, however, is sometimes difficult even for the experienced. 
If there has been much delay the scalp tissues may be swollen and the 
sutures difficult or impossible of recognition. In these cases there is one 
infallible method — the introduction of the half hand into the cavity of 
the sacrum and the palpation of the posterior ear. If the ear points 
posteriorly so must the occiput, and if the ear points to the right or left, 
so must the occiput. This method I have many times found most useful. 

Let me pause here to impress upon the minds of all who are interested 
in this subject the importance of learning how to diagnose posterior posi- 
tions of the occiput. The subject has been generally neglected. Failure 
in this respect may be fraught with the most unfortunate consequences. 
An impacted posterior occiput wrongly treated is one of the tragedies of 
obstetrics. The application of the forceps in unrecognized occiput 
posterior cases and the succeeding unskilful attempts at delivery have 
often resulted disastrously, as I have myself seen more than once. 

Effect Upon Labor. — In about 90 per cent, of these cases, i.e., in the 
cases in which the occiput rotates to the front without difficulty or delay, 
the clinical history does not differ from that of ordinary uncomplicated 
labor. In the balance of the cases the history is that of delayed labor, and 
in unrecognized or neglected cases that of uterine exhaustion. 

If the head cannot enter the brim the first stage is prolonged and the 
suffering severe, as it always is when there is long-continued reciprocal 
pressure between the head and the bony pelvis. The cervix dilates slowly 
and incompletely and finally dilatation ceases altogether. 

Complete arrest may take place in the mid-pelvis or, much more com- 
monly, at the pelvic floor. In these cases the impression one gets is that 
the natural forces are sufficient but are working in the face of some 
insuperable obstacle. In spite of uterine contractions that are normal in 
force and frequency, and are aided by desperate efforts of the patient, 



^lALPOSITIOXS AND MALPRESENTATIONS 373 

no progress is made, and the conclusion is forced upon even the most 
inditterent or careless observer that interference is not only justified but 
imperatively demanded. Sometimes rotation occurs at the last moment 
and contrary to all expectation, but this happy result cannot always be 
depended upon. 

In the first place it is a mistake to suppose that every occiput posterior 
case needs active treatment or operative interference. Nothing could be 
more ill-advised or mischievous. In the great majority of cases the 
efi'orts of nature are sufiicient to bring about a happy termination. The 
attitude of the physician, then, in cases of delay should be one of watchful 
attention. Something may be done by keeping the bladder and rectum 
empty, by having the patient lie upon the side toward which the occiput 
is directed, and by the cautious use of anodynes, for the relief of excessive 
sultering. If the condition of the mother remains good, the physician will 
not make haste to interfere, even though progress be slow. On the other 
hand, however, he will not permit the development of maternal exhaustion 
and will not neglect to keep himself informed as to the condition of the 
foetus. 

Assuming then that delivery is indicated, the treatment will vary with 
the position of the fetal head. If it remains above the brim the proper 
treatment, as we have already seen, is version. The difficulties of the 
high forceps operation are sufficiently great in anterior positions, and in 
posterior positions they are vastly increased. 

]\Ianual rotation of the head above the brim to an anterior position has 
been advocated, but an anaesthetic is required and the posterior position 
is likely to recur, making version necessary in the end. Moreover, this 
high rotation is about as formidable an operation as is an easy version. 

If the head passes the brim but is arrested in the pelvic cavity version 
may still be practicable and, if so, is safer than an attempt to deliver with 
the old model forceps, if one is not an expert at forceps delivery. If, 
however, the operator is provided with an axis traction forceps and under- 
stands its use, the blades should be applied to the sides of the head, or 
as nearly as possible, and moderate traction made, aided by supra-pubic 
pressure. In this way descent can usually be effected and as a rule the 
occiput will rotate forward as it reaches the pelvic floor. This rotation 
may be encouraged by imparting a rotary motion to the true handles while 
making traction upon the traction handles. No great force should be 
used. In no condition is the wonderful efficiency of the Tarnier instru- 
ment better illustrated than here. I have performed this manoeuvre many 
times with the greatest satisfaction. Before the forceps are removed 
simple pressure upon the fundus suffices to complete rotation. 

In the great majority of cases, however, the head has reached the 
cavity of the pelvis before progress is arrested. In these cases an ordinary 
forceps may be applied and the head rotated. A straight forceps, or one 
with a very moderate pelvic curve, is to be preferred. This is a good 



374 



PATHOLOGY OF PREGNANCY AND LABOR 



illustration of the fact that the practitioner should be provided with two 
pairs of forceps. The procedure is fully described in the chapter on the 
forceps operation, q.v. 

Manual rotation of the head by the hand in the vagina is advised 
and practised by many. The external hand is applied to the abdominal wall 
and aids the manoeuvre by pushing the posterior shoulder in the direction 
in which it is desired to rotate the head. The forceps are then applied. 
I have not found it necessary to practise this method, because it is much 
less certain than rotation with the forceps, and I have been uniformly 
successful with the latter, but there is no doubt that it is sometimes 




Fig. 212. — Delivery in the occipitosacral position. 



Fig. 213. 



-Delivery in posterior position. 
External restitution. 



successful. It is a useful expedient in case the operator does not have 
a Tarnier forceps, or has not the necessary experience or confidence to 
rotate the head with the ordinary instrument. The introduction of the 
hand into the vagina, especially if the operator has a large hand and the 
patient is a primipara, is by no means desirable. 

If the occiput has rotated into the hollow of the sacrum, artificial 
rotation is, of course, out of the question. The head must be delivered 
with the occiput posterior (Figs. 212 and 213). For this a special technic 
is necessary, and this, too, wi!l be found in the chapter on the forceps 
operation. 



MALPOSITIONS AXD MALPRESENTATIONS 375 

Transverse Presentations 

Strictly speaking, a transverse position of the foetus is one in which 
the long axis of the foetus corresponds to the transverse axis of the uterus. 
With the full-term foetus, however, this is hardly possible, and so it comes 



^i^^^' 





Fig. 214. — External appearance in transverse position. 

about that in practice most so-called transverse presentations are in reality 
presentations of the shoulder, the long axis of the foetus being oblique 
rather than transverse. 

Etiology. — Anything that prevents the engagement of the head, e.g., 



376 



PATHOLOGY OF PREGNANCY AND LABOR 



contracted pelvis, unusual size of the head, tumor, or placenta praevia, 
may cause transverse presentation. 

Again congenital deformity of the uterus (the cordiform or heart- 
shaped uterus) may make it impossible for the foetus to assume the longi- 
tudinal position. In such cases successive labors are thus complicated. 

Most common of all are those conditions which increase the mobility 
of the foetus. Multiparity is a predisposing cause, since pregnancy 
increases the transverse diameter of the uterus. Hydramnion, twin- 
pregnancy, and small size of the foetus act in the same way. 

Diagnosis. — -Inspection. — In many cases the practised eye notes that 
the uterine ovoid is transverse rather than longitudinal (Fig. 214). This 




Fig. 215. — Palpation in longitudinal position. 

can sometimes be made very apparent by placing a hand on either side 
of the abdominal tumor, as in Fig. 215. However, one cannot depend upon 
this method of diagnosis alone. 

Auscultation. — The fetal heart-sounds are heard in the neighborhood 
of the umbilicus, usually somewhat below. They are most distinct upon 
the side toward which the head is directed. On the whole it is somewhat 
more difficult to locate the fetal heart-sounds than in vertex presentations. 

Palpation. — Here, as in breech presentations, one feels for the head 



JMALPOSITIOXS AND MALPRESENTATIONS 



377 



in its usual position and fails to find it. The position then must be trans- 
verse, or perhaps the breech may present ; but the fundus is not as high 
as usual and its characteristic outline is lacking. Further search will 
usually reveal the head in one iliac fossa and the other fetal pole diago- 
nally opposite under the heart or liver. Or the positions of the fetal and 
cephalic poles may be reversed. With one hand at either pole external 



l 










Fig. 2i6. — Palpation in transverse position. 



ballottement may be practised. The fetal position is no longer in doubt 
(Fig. 218). 

After labor is in progress, and especially after the membranes have 
ruptured, the diagnosis by external methods is less easy. The foetus is 
doubled upon itself and neither palpation nor ballottement is satisfactory. 
But the shoulder has become crowded down into the inlet where it is 
accessible to internal examination and furnishes valuable information. 

Of course, when we speak of the shoulder in this connection we do 
not mean simply the bony point or ''tip " of the shoulder but we include as 



378 



PATHOLOGY OF PREGNANCY AND LABOR 



well the structures immediately surrounding it. A'iewed in this way the 
most typical thing about the shoulder is the adjacent portion of the chest 
wall, the gril intercostal of Pajot or the intercostal gridiron, as it has 
been called in English. Nothing else like this is encountered in the whole 
course of vaginal examination. The examining finger in the axilla feels 
the ribs and the depressions between them. Hence the name gridiron. 







:uj^- 



-A \>- .., 




Fig. 217. — Shoulder presentation. Palpating hand grasps the head. 

Having found this, it is easy to reconstruct in imagination the position 
of the foetus. Of course the upper (closed) part of the axillary space 
points toward the head and the lower toward the feet, while the collar- 
bone, easily recognized, marks the anterior surface of the foetus. If a 
prolapsed hand protrudes, as is often the case, and the accoucheur grasps 
it, he grasps the hand of the same name as his own. 



MALPOSITIONS AND MALPRESENTATIONS 379 

Diagnosis is here of prime importance, because it is the only key to 
correct treatment, and nowhere in obstetrics does more depend on correct 
treatment than in the management of transverse positions. 

Influence Upon Labor. — Owing to the fact that the shoulder, which 
is at best a poor dilator of the cervix, descends but slowly, the first stage 
is delayed. There is nothing to keep back the amniotic fluid and, as in 





Fig. 2 1 8. — Ballottement in case of shoulder presente.tion. 

pelvic contraction, the membranes protrude from the cervix in a long 
pouch. Premature rupture is common. 

After a time the shoulder becomes impacted in the pelvic brim and 
progress ceases. The lower uterine segment becomes very much thinned 
and closely applied to the foetus. The pain is severe and there is no 
complete relief, even between the contractions. There is marked tender- 



380 PATHOLOGY OF PREGNANCY AND LABOR 

ness over the lower uterine segment, and the other signs of impending 
rupture of the uterus are not long delayed. 

Strictly speaking, there is no mechanism of delivery in these cases. 
Nature does not intend that the patient shall be delivered in this way. 
If the foetus is of normal size, its delivery per vias nat urates is practically 
impossible. Now and then, if the foetus is small and flexible, it may find a 
way of escape in the so-called spontaneous evolution. Lender the influence 
of the uterine contractions the fetal trunk is bent sharply upon itself, 
the shoulder is crowded behind the symphysis, where it becomes fixed, 
and the breech is forced past the shoulder and through the vulva. This 
phenomenon, which the student must study but which he will probably 
never witness, is shown in Figs. 219, 220, 221 and 222. 

Treatment During Pregnancy. — Theoretically, the treatment for 
transverse position during pregnancy is external version. L^nfortunately, 
the conditions which caused the original are likely to cause its recurrence. 
Nevertheless the procedure, if carefully performed, is harmless and for 
that reason is always worthy of trial. The subject is discussed, and the 
operation of external version is described and illustrated in the chapter 
on version. 

Treatment During Labor. — Early in labor and before rupture of 
the membranes it may still be possible to bring the head by external manipu- 
lations from its position in one or the other iliac fossa to the pelvic brim. 
Much more often the task is accomplished by the contractions themselves 
and the necessity for operation disappears. I have known this to happen 
when the foetus seemed firmly fixed in its abnormal position, prudent 
efforts at external version being unsuccessful. 

If the transverse position is not or cannot be corrected great care 
should be taken to prevent premature rupture of the membranes. During 
this period the physician should not be long absent from his patient since 
the membranes might rupture and subsequent version be difficult or 
perhaps impossible. 

If the membranes have already ruptured treatment should be instituted 
without delay. Here there is no sense in waiting on nature and conserva- 
tism can only end in disaster. The treatment consists in bringing down 
a foot by the operation of version. When this has been done the danger 
to the mother is practically over. Early in labor, before much liquor 
amnii has drained away, the operation is easy. Later it may be difficult 
or impossible. 

Aversion in these cases presents certain special features which merit 
careful attention. In the first place, there has been little or no dilatation 
of the cervix and consequently manual dilatation should be performed 
with care before delivery is undertaken. In this way subsequent difficulty 
in extraction is best avoided. In the second place, since the hand of the 
operator is seeking a fetal foot the left hand should be used when the 
feet are on the mother's left side, and vice versa. 



MALPOSITIONS AXD MALPRESENTATIONS 



381 




r-^-^. 



Fig. 219. — -Spontaneous evolution, first stage. 




:> 




> 



P 



Fig. 220. — Spontaneous evolution, second stage. 



Fig. 221. — Spontaneous evolution, third stage. 



s — f 




Fig. 222. — Spontaneous evolution, fourth stage. 



382 



PATHOLOGY OF PREGXAXCY AND LABOR 



In the third place, anterior rotation of the back is favored by bringing" 
down the lower foot in dorso-anterior positions, and in the less common 
dorso-posterior positions the upper foot. 

All this, which is rather difficult to explain in print, will be made clear 




Fig. 223. — Version for transverse position. Back anterior. 



by the accompanying illustrations (Figs. 223, 224, 225 and 226). For 
example, it is not necessary to explain to the reader why in Fig. 224 the 
operator is using his left hand in preference to his right. 

These rules, however, are to be used as guiding principles rather than 



^lALPOSITIOXS AND MALPRESENTATIONS 



383 



arbitrary dicta. They are aids rather than objects in themselves. As 
Biimm has wittily said, there are few obstetricians who, having finally 
succeeded in reaching and grasping a foot, will release it because theoreti- 




FiG. 224. — Version for transverse position. Back anterior. 

cally it is not the right one, and pursue the search for another. Time is 
too precious for this. , 

In neglected cases, when the fluid has drained away and the lower 
uterine segment has become tightly applied to the foetus, great care must 
be used. The operator must know how to utilize every possible advantage. 
The patient should be conveniently placed upon a firm table. Profound 



384 



PATHOLOGY OF PREGXA^XY AND LABOR 



narcosis is sometimes necessary and the lateral position is of great advan- 
tage. It is sometimes possible to bring down a foot with the patient in the 
lateral position when this cannot be done with the patient upon her back. 
I can speak upon this point from experience. Seldom seen in print, it is 
yet one of the most important facts in clinical obstetrics. 




Fig. 225. — Version for transverse position. Back posterior^ 



Prolapse of a hand and arm is a frequent complication. The hand 
should be secured by a fillet and held to one side until version has been 
performed. The inexperienced accoucheur often has the idea, not unnat- 
ural, that the arm should be replaced, but this would only make the 
subsequent extraction of the after-coming head more difficult. 



MALPOSITIONS AND MALPRESENTATIONS 



385 



Breech Presentation 
In breech presentation, or pelvic presentation, as it is more commonly 
called, the pelvic end of the foetus presents. Usually the nates are first 
felt by the examining finger and the feet are within easy reach. This is 
called a full breech. ]\Iore rarely the legs are extended upon the fetal 
body as upon a splint and the feet are in the region of the face. This is 




Fig. 226. — Version for transverse position. Back posterior. 

a breech presentation with extended legs or, as it is sometimes called, 
a '' frank " breech and is of clinical importance, as we shall presently see, 
since it may give rise to great difficulty in delivery. Foot, or, to use the 
quaint vocabulary of the older writers, '' footling," are simply compli- 
cations of breech presentation. This is also true of the much more rare 
knee presentation. 
25 



3S6 



PATHOLOGY OF PREGNAXX^Y AND LABOR 



Frequency. — It is said to occur in about 3 per cent, of all cases. 
Etiology. — Breech presentation is usually the result of lack of accom- 
modation between the head and the pelvic brim, e.g., pelvic contraction, 
or unusual size of the fetal head, which is relatively the same thing. It 
may be caused by anything which obstructs the entrance to the pelvic 
brim, tumor, placenta prsevia, the head of a twin, etc. When the foetus 
has much freedom of movement in the uterine cavity breech presentations 
are more common. Hence they are oftener found in the lax uterus of a 
multipara, when the foetus is macerated, premature, or very small, and 

when there is an excess of amniotic fluid. 
Uterine obliquity may be a cause (Fig. 22^), 
Mechanism. — There is usually no great 
difficulty in the passage of the breech 
through the pelvic brim, though it is always 
found above the brim at the beginning of 
labor. Even in primiparas it does not 
descend into the cavity of the pelvis during 
the latter weeks of pregnancy. 

As in normal labor the occiput is the in- 
dex of presentation, so in breech presenta- 
tion is the sacrum — at least nominally. In 
practice the anterior hip corresponds to the 
occiput, and it is this that we have to consider 
if we would make the process intelligible. 

Owing to the comparatively small size of 
the breech there is usually no opposition at 
the brim of the pelvis, and the breech de- 
scends to the pelvic floor without the neces- 
sity of any special mechanism. Progress is usually slow during the first 
stage, owing to the fact that the breech is a poor dilator of the cervix. 

Just as the occiput strikes the pelvic floor first in normal labor and is 
deflected to the median line, so in breech presentation does the anterior 
hip, which is normally somewhat in advance of the posterior, rotate under 
the pubic arch, bringing the bitrochanteric diameter, the longest diameter 
of the breech, into coincidence with the anteroposterior diameter of the 
outlet, where there is the most room. 

Thus the anterior hip again takes the place of the occiput at the 
subpubic arch. If now the breech were driven '' wnward and forward 
in a straight line it would of necessity plough its way through the perineum, 
but, as in head presentations, the bending of the neck permits the extension 
of the head, and its consequent expulsion, so the flexible trunk of the child 
allows the posterior hip to be expelled by a similar mechanism. 

After the birth of the hips the body, if of normal size, follows without 
trouble, the shoulders rotating until the bisacromial diameter becomes 
anteroposterior at the outlet (Fig. 228). 




Fig. 227. — Diagram showing how 
obliquity of the uterus produces foot- 
ling presentation. (After Kiistner.) 
(Herman's Difficult Labor, Wm. Wood 
& Co.) 



MALPOSITIOXS AND MALPRESENTATIONS 387 

If everything proceeds normally the arms remain folded across the 
chest and the head well flexed. x\fter the shoulders are delivered they 
undergo a movement of external rotation, making the bisacromial diameter 
again transverse, while the head rotates internally until the back of neck 
comes to lie under the subpubic arch. Face and forehead then sweep over 
perineum, chin, mouth, etc., appearing in order until expulsion is complete. 

Unfortunately, unless the child is very small, the normal mechanism of 
expulsion in these cases is the exception rather than the rule. Either 
premature traction has been made, causing extension of the head and 




Fig. 228. — Lateral flexion of fetal body in breech presentation. (Hodge.) 

arms, or after the birth of the hips delivery is so long delayed that in spite 
of pressure upon the head through the fundus extraction becomes neces- 
sary with the same result. 

In some cases the fetal back and occiput rotate posteriorly with the 
result that the chin instead of the occiput rotates under the pubic arch. 
In this case the fa"'^. sweeps under the subpubic arch instead of over 
the perineum. This posterior rotation should not occur if the operator is 
on his guard. It is to be prevented by guiding the back forward during- 
the expulsion of the breech. It Is always an evidence of clumsiness or 
carelessness on the part of the operator. 

Diagnosis. — The competent examiner should be able to make the 
diagnosis by external examination. The first thing that he will notice is 
the absence of the head from Its usual position. This Is the key to the 



388 



PATHOLOGY OF PREGNANCY AND LABOR 



diagnosis. The absence of the head from its usual position can be more 
easily determined than its presence at the fundus, where it is somewhat 
more difficult to palpate. Having determined this absence, and having 
excluded a transverse presentation by the rules already given, we can 
proceed to find the head at our leisure. 

Palpation. — As in vertex presentations, the back may be felt on one 

4 




s •■-iil^^" 



Fig. 229. — Palpation of the shoulder in breech presentation. 

side and the small parts on the other. The shoulder also may be palpated, 
but the foetus as a whole is more movable than in vertex presentations 
and the findings less satisfactory. The head, however, can always be 
made out unless the abdominal wall is very thick. Ballottement may also 
be obtained (Figs. 229, 230 and 231). 

One often reads that in breech presentation the fetal heart-sounds 
are necessarily heard above the umbilicus. This is not the case nor is 



[MALPOSITIONS AND AIALPRESENTATIONS 



389 



there any particular reason why it should be. The statement is likely 
to lead to grave errors in diagnosis. In these cases the fetal heart-sounds 
are often best heard at or below the level of the umbilicus. 

Internal Examination. — If the membranes have been ruptured and 
the breech is well down in the pelvic cavity the diagnosis is easy. The 
sacrum and anus and. in the male, the scrotum should be recognized 



.^-^"^ 



y 



/ 

1: 



\^.. 




Fig. 230. — Palpation of the head in breech presentation. 

without difficulty. The finger may be smeared with meconium. On the 
whole, however, such descriptions serve to confuse, rather than to 
enlighten. To tell the reader that there are no eyes in the breech, that 
the finger in the anus does not feel the jaws, etc., borders upon the 
ludicrous. 

There are cases in which the diagnosis by digital examination is not 
immediately possible. These are the cases in which the presenting part 



390 



PATHOLOGY OF PREGNANCY AND LABOR 



is far above the brim of the pelvis and can barely be reached by the 
examining linger. If the examiner relies solely upon the evidence afforded 
by digital examination he may be for a time in doubt. He feels certain 
that he is not dealing with a vertex presentation. It may, however, be one 
of the face or possibly of the shoulder. The introduction of the hand 
would settle the question but in the absence of a distinct indication this 



^ 



- / 



^^ 



"M 






Fig. 231. — Ballottement in case of breech presentation. 

is hardly justifiable. External palpation, however, reveals the head, which 
in a case like this is above the brim and easily palpable and excludes the 
possibility of breech presentation. 

Prognosis. — There should be no special maternal mortality in cases 
of breech presentation carefully and aseptically conducted, but owing 
to the necessity for rapid delivery of the after-coming head there is con- 
siderably more risk of perineal laceration, sometimes unavoidably severe. 
The fetal mortality, however, is considerably higher than in normal labor. 



MALPOSITIOXS AND MALPRESENTATIONS 391 

It is usually estimated as one in ten, but no accurate estimate is possible 
since the matter depends almost altogether upon the skill and experience 
of the attendant. It is safe to say that it is greater in primiparae, owing 
to the greater difficulty in the delivery of the head. 

Effect Upon Labor. — The first stage is long and tedious ; in some 
cases intolerably so. This is due to the fact that the breech is a poor 
dilator of the cervix. The amniotic fluid escapes beside the small irregular 
breech and distends the protruding sac and, as in transverse positions, 
early rupture is common. This tends still further to delay the progress 
of labor. 

Early rupture of the membranes and a long and wearisome first stage, 
then, are frequent accompaniments of breech presentation. The second 
stage, however, is usually much shorter. The breech finds no great 
obstacle to its passage in the pelvic cavity or at the vulva, and the after= 
coming head must be delivered quickly. 

Treatment. — Great patience and tact are called for in the management 
of the first stage. Since the early rupture -of the membranes is a distinct 
disadvantage it is wise for the patient to lie down during the first stage. 
This is contrary to the usual rule but the advantages of the recumbent 
position here outweigh the disadvantages. 

The attendant must have the resolution to resist the importunities of 
the patient and her friends. All interference within the passages and 
especially all efforts to hasten delivery by traction are to be avoided. 
Such efi:orts tend to reverse the normal mechanism, cause extension of the 
head and arms, and thus delay the delivery of the after-coming head and 
perhaps cause the death of the child. As long as progress is being made 
and the mother's condition is satisfactory an expedient policy is indicated, 
^leanwhile something may be done by the use of chloral or by the cautious 
use of morphine, or of morphine and hyoscine, hypodermatically, to alle- 
A'iate the patient's sufferings during the long hours that nature occupies 
in the process of cervical dilatation. 

As soon as the second stage approaches the patient should be placed 
in the cross-bed position, or, still better, upon a table with her hips drawn 
Avell over the edge. Under no circumstances should delivery be attempted 
with the patient lengthwise in bed. This is deliberate trifling with- fetal 
life. 

Profound narcosis is undesirable since the voluntary eff'orts of the 
patient aid materially in the delivery of the breech, and traction is, for the 
reasons stated above, to be avoided. Pressure upon the fundus, however, 
aids materially and has no disadvantages. If the suffering is aciite, or the 
patient over-sensitive, she may be induced to '' bear down " by the adminis- 
tration of a few drops of ether with each contraction. The posterior hip 
should be guided in such a way as not to plough through the perineum. 

When the breech appears at the vulva, however, there must be a 
complete reversal of policy. At this time pressure upon the cord and 



392 



PATHOLOGY OF PREGNANCY AND LABOR 



H 



corresponding danger to the foetus begin. The danger is much greater 
in primiparse. The problem at this time is rapid deHvery. He who would 
succeed in the management of breech presentation must know how to 
deliver the after-coming head. 

The proper technic of the delivery of the after-coming head should 
be followed out in every detail. The matter is fully considered in connec- 
tion with the operation of version, of which it is an essential part. 




Fig. 232. — Breech presentation with legs extended. Ready to flex the knee, first step. 



Of course, the expectant treatment of the first stage is not always 
practicable, though it should be followed whenever the interests of the 
mother permit. In breech presentation, as in that of the vertex, arrest of 
progress may occur and artificial aid may be demanded. This is best 
rendered by bringing down a foot. Sometimes the foot is within easy 
reach and the matter is perfectly simple. In other cases the legs are 
extended along the body of the child and the feet almost as high as the 
head, as in Fig. 27,2. In this case a foot can usually be reached by the 
method of Pinard. The patient is anaesthetized and prepared as for 



:MALP0SITI0NS and MALPRESENTATIONS 393 

version. The choice of hand is also the same as for version; i.e., the 
hand whose pahiiar surface when held half-way between pronation and 
supination will correspond to the abdominal surface of the child. This 
is introduced as in version and insinuated very slowly and gently, its 
palmar surface toward the belly of the child and its dorsal surface toward 
the uterine wall until the tips of the fingers reach the flexure of the knee. 
At this point pressure is made, so as to flex the knee and bend it a little 



./ 




Fig. 233. — Breech presentation with legs extended. Bringing down a foot, second step. 

outward. This usually suffices to bring the foot within reach of the 
finger. The operator should recall that it is the anterior foot which he 
is seeking. The reasons for this are given in the chapter on version 
(Fig. 233). 

In some cases there may be no room for the passage of the hand, 
and even the introduction of the finger into the groin is impossible or 
ineffectual. In this dilemma we are reduced to the necessity of a choice 



394 



PATHOLOGY OF PREGNANCY AND LABOR 



between several rather unsatisfactory methods : the forceps, the fillet, and 
the blunt hook. The forceps is not an ideal instrument for application 
to the breech, but it is in my opinion more eiTectual and less dangerous to 
the foetus than either of the other two instruments. Its use in this emer- 
gency has been discussed in the chapter on the forceps operation. Con- 
tinuous moderate traction, with firm pressure on the fundus by an assist- 
ant, often suffices to bring the breech within reach of the finger when the 
latter can be hooked into the groin and delivery thus completed. Of 
course, no attempt is made to complete the entire delivery with the forceps. 
The deliver}^ of an impacted breech is one of the most difficult tasks 
which the accoucheur is called upon to perform. For this reason it is the 




34- — Releasing the anterior hip. 



practice with some to bring down a foot early in labor, while the task is 
yet easy, thus providing a *' handle " to be used in subsequent emergencies. 
The adoption of this measure as a routine practice \vould undoubtedly 
do much more harm than good. It should be reser\'ed for those cases 
in which there is reason to believe that there is marked disproportion 
in size between the foetus and the maternal parts, e.g., in the case of a 
patient who has gone over her time and w^ho has a history of difficult labors 
and large children. 

In easy cases, or when the breech is well down in the pelvis, the finger 
in the groin answers every purpose. It should first be hooked into the 
anterior groin and traction made downward and as far backward as 
possible until the posterior hip begins to distend the perineum. Traction 



MALPOSITIONS AND MALPRESENTATIONS 



395 



may be aided by grasping the wrist. The finger is then changed to the 
posterior groin and traction made directly upward. The use of both 
hands mailing traction in both groins, so often figured in the text-books, 
I have not found necessary and beheve that it imposes an unnecessary 
strain upon the perineum. Pressure upon the fundus aids very materially 

(Fig. 234). 

The danger of asphyxia after breech deliveries is considerable and 
the attendant should on no account neglect to have in readiness such 
assistance and appliances as are necessary for its proper treatment. 

Unlike most of the malpresentations those of the breech are relatively 
common. The danger to the foetus is so great that it behooves the prac- 
titioner to make a careful study of the subject. For this reason I venture 
to sum up what seem to me the most 
important points. 

The first stage should be treated 
expectantly. Every eft'ort should be 
made to avoid rupture of the mem- 
branes. Attempts to hasten delivery 
by traction should be studiously 
avoided. 

As soon as the breech appears at 
the vulva, deliver}^ should be hastened 
as much as possible. 

The operator should know how to 
deliver the extended arms and the 
after-coming head in time to save the 
child. This is by far the most im- 
portant part of the treatment. Many 
men are deficient in this respect. F1G.235. 
Many men who can do good emergency 
work in surgery, who, for example, could treat promptly and successfully 
an appendicular abscess or a strangulated hernia, are unable to perform 
this every-day procedure upon which the life of the child and the happiness 
of the mother depend. He who would undertake the responsibility of 
these cases should learn the technic in advance. 

Face Presentation 

This is a rather rare anomaly occurring, according to Pinard, once in 
250 cases. 

Etiology. — Face presentation is an example of extreme extension and 
the causes are those of extension in general, already mentioned. Marked 
latero-version has been adduced as a special cause. This is more easily 
illustrated than described and is well shown in Fig. 235. Certain fetal 
anomalies may act as causes. The dolichocephalic head obviously has a 
tendency to cause extreme extension, and a hemicephalic would naturally 




— Face presentation due to latero-ver- 
sion of the uterus. (Ahlfeld.) 



396 



PATHOLOGY OF PREGNANCY AND LABOR 



result in a presentation of the face, though in the latter case it would have 
no special clinical significance. Examples of marked extension caused 
by direct mechanical interposition are sometimes found in tumors of the 
throat, or in the presence of a prolapsed hand or arm under the chin. 

Mechanism. — The head may come down in a condition of extreme 
extension, the face entering the brim directly, but more commonly the 
brow is first caught at the brim, the face being brought down as the result 
of further extension. Descent goes on caused by the same factors that 
obtain in normal labor, but rotation occurs much earlier ; probably because 
the presenting diameter is much longer. Unfortunately the chin is usually 
posterior at the brim and it is in these cases that the '' long rotation," 



Fig. 236. 




Fig. 237. 




Fig. 236. — Anterior rotation of chin in R. M. P. position. Three-eighths of a circle. 
Fig. 237. — Anterior rotation of chin in L. M. A. position. One-eighth of a circle. 

three-eighths of a circle, is necessary (Figs. 236 and 2'i^y^. It is this long 
rotation that makes most of the trouble in face presentations. Here again 
we have an example of the practical value of a knowledge of the mechan- 
ism of labor. Not only is the cause of delay made plain but if the attendant 
finds the chin posterior early in labor he is reassured by a knowledge of 
the fact that the posterior position occurs as a passing phenomenon in the 
great majority of cases. 

After the chin has rotated to the front the region beneath the chin, 
the sous menton as the French call it, becomes fixed under the pubis 
and the head is bom by a movement of flexion, mouth, nose, eyes, fore- 
head, vertex and occiput successively making their appearance at the vulva. 

Diagnosis. — One who is a master in external diagnosis will sometimes 



MALPOSITIONS AND MALPRESENTATIONS 



397 





be able to make a diagnosis without internal examination. The condition 
is usually overlooked, however, because it is so rare that one does not think 
about it. 

Let us take the most common of the face positions, the right mento- 
posterior. The back, as in all right posterior positions, is far away from 
the median line and, owing 
to the backward projec- 
tion of the occiput, is 
palpable to a less extent 
than usual. The latter is 
notably prominent and 

makes a sharp angle with _^ ^ 

the back, the dorso-occipi- / ^^ 

tal angle of face presenta- / .; 

tion, as I have ventured / h^ ^^ 

to call it. Between the \ \ '"'''~y 

occiput and the back is a i 

deep depression corre- \ -^._^/ 

sponding to the back of . \ 2/ 

the neck. ' \ ; 

Anteriorly and to the "" 

left are felt the small 
parts. Owing to the for- 
ward protrusion of the 
chest, the fetal heart, 
sounds w^ith more than 
ordinary distinctness. Be- ^^-^ 

fore the beginning of: 
labor, and as long as the ' 
head remains above the 
brim, they are usually 
heard not far from the • 
median line, in the neigh- 
borhood of the umbilicus. % 

Internal Examina- 
tion. — The face, if acces- 
sible, can be confounded 
only with the breech. Its 
distinguishing features are ^- 

the orbits and the nose. ^'''- 238.-Face presentation. 

It is said that the anus has more than once been mistaken for the mouth 
and even for the undilated cervix. // the face is high and difficult to 
reach, or if it is much swollen the diagnosis by internal examination 
may present considerable difficulty. If the attendant is in doubt, how- 
ever, external palpation will settle the question. Should the presenta- 



^ 



398 



PATHOLOGY OF PREGNANCY AND LABOR 



tion be one of the breech or shoulder the head cannot be found at the 
brim or in the cavity of the pelvis. Here we have another instance of the 
value of external examination (Figs. 238, 239 and 240). 

Treatment. — First of all a careful measurement of the pelvis is in 
order. Pelvic contraction and face presentation often go together, the latter 
being the result of the former. In such cases it is the pelvic contraction, 
not the face presentation, that is the primary object of treatment. 

If the child is of great size the conditions are relatively the same, and 
the treatment should be the same, but unfortunately our methods of 
determining the size of the fetal head are still unsatisfactory. 

Every care should be taken to prevent premature rupture of the mem- 
branes and physician and patient should try to make the best of the long 




Fig. 239. — Mechanism in face presentation, chin anterior. 

first stage that is characteristic of these cases. The sufferings of the 
patient should be lightened by the judicious administration of chloral or 
some other anodyne. 

Interference is not indicated simply because the face presents, but only 
as the interests of mother or child demand, and the attendant should 
remember that forward rotation of the chin, like that of the occiput, often 
occurs at the last moment and contrary to all expectation. Vaeinal exam- 
inations should be made very carefully In order to avoid injuring the eyes 



MALPOSITIONS AND MALPRESENTATIONS 



399 



of the child or causing excoriations of the swoUen face. The physician 
should remember that in face presentation a face tumor takes the place 
of the scalp tumor, giving the child a most unprepossessing appearance. 
Of this it is well to advise the parents in advance. 

If interference is demanded and the head is still above the brim the 
best treatment is version. Intra-uterine manipulations intended to con- 
vert the position into one of the occiput are not likely to succeed and are 
in themselves not altogether free from danger. In the second stage 
cautious eltorts to produce anterior rotation of the chin by pushing up the 
forehead or by hooking the chin forward with two fingers may be tried. 




Fig. 240.— Face presentation. Chin has rotated posteriorly. Arrest of labor. 

but too much time should not be spent in this way. It is said that anterior 
rotation is favored by having the patient lie upon the side toward which 
the chin is directed and while the efficacy of this procedure is probably 
not very great it has at least the merit of doing no harm. 

When the head is arrested well down in the cavity of the pelvis with 
the chin anterior, the forceps should be applied, lege artis. The technic 
of their use in face presentation is given in the chapter on the forceps 
operation, which the reader is advised to look over with care. 

If the foetus is of normal size its delivery with the chin posterior is 
mechanically impossible. In such cases a cautious attempt at rotation with 



400 PATHOLOGY OF PREGNANCY AND LABOR 

forceps or hand, preferably the latter, may be made. If it does not suc- 
ceed and conditions are not favorable to the performance of pubiotomy or 
the Csesarean section, perforation may be the only alternative (Fig. 241). 

Brow Presextatiox 
This is a rare complication of labor. Its frequency has been esti- 
mated as about one in three thousand. I knew one teacher of obstetrics 
who refused to admit its existence because he had never seen a case. 




Fig. 241. — Face presentation, the head markedly extended. 9.5 centimetres, submento-bregmatic 
diameter; 13.5 centimetres, presterno-sincipital diameter. 

Doubtless presentation of the brow occurs as a passing phenomenon in the 
majority of face cases, since it is evidently the result of an arrest of the 
process of extension. But we are speaking here of persistent presentations 
of the brow. Of these I can recall meeting with but two. 

The presenting part is the brow, i.e.^ the region bounded by the root 
of the nose and the region of the large fontanelle. The diameter which 



.MALPOSITIONS AND MALPRESENTATIONS 



401 



engages in the pelvic brim is the occipito-mental, measuring 13.5 cm., 
the greatest diameter of the fetal head. This fact explains at once the 
fonnidable nature of this complication (Fig. 242). 

Etiology and Mechanism. — Owing to the rarity of this complication 
opportunities of studying its etiology and observing its mechanism have 
been comparatively few. It is fair to assume, however, that the causes 
are practically the same as those of face presentation, i.e., that they are 
the general causes of extension of the head. Bumm suggests that unusual 




Pig. 



242. — Brow presentation, the head moderately extended. 

diameter. 



13. 5 centimetres, sincipito-mental 



size of the head may make full extension difficult or impossible and this 
accords with my own observation. 

Mechanism. — In some cases, in fact in many cases, it is impossible for 
the long diameter to become engaged in the pelvic brim and natural 
delivery cannot occur. If contractions are good, however, and the dis- 
proportion not too great, the occiput is driven forward between the two 
parietals while the chin is also pushed back and the maxillary condyles 
as well. In this way a reduction of 1.5 cm. is brought about. 
26 



402 



PATHOLOGY OF PREGXAXCY AND LABOR 



Of course the process is slow and difficult, and this is true of the 
descent and rotation that follow, and by means of which the root of the 
nose is finally brought beneath the symphysis. ]\Iouth and chin follow. 
Under the influence of the uterine contractions the head becomes markedly 




Fig. 24o. — Derormation of the head in brow presentation. 

flexed, a superior maxillary bone becomes fixed at the subpubic arch, as 
does the suboccipital region in normal labor, and brow, vertex and occiput 
are swept over the perineum as the result of the flexion. As soon as this 
has occurred the head naturally drops back and as extension occurs nose, 
mouth and chin pass under the pubic arch. 



MALPOSITIONS AND MALPRESENTATIONS 403 

Configuration of the Head. — Fig. 243 (Fabre) well shows the peculiar 
conliguration of the head in these cases. The mouth is open and both 
chin and occiput, opposite poles of the diameter of engagement, show the 
pressure to which they have been subjected in passing the brim of the 
pelvis. The forehead is swollen and the top of the head has a dome-like, 
somewhat pointed, appearance. The distance from the ear to the top of the 
head is much greater than normal. 

Diagnosis and Clinical History. — External examination does not give 
the same accurate information as in presentation of the face. The dorso- 
occipital angle is present, but is hardly prominent enough to warrant a 
positive diagnosis. 

Internal examination gives positive results. The large, soft anterior 
fontanelle near the middle of the field is the first thing to attract attention. 
This, however, is often within easy reach in posterior positions of the occi- 
put. Certainty is attained by the fact that on further examination one can 
feel the orbits and root of the nose. The fact that the chin cannot be 
reached shows extension is not sufficient to constitute a face presentation. 

Prognosis. — Reliable statistics are not at hand but there is no doubt 
tb.at the prognosis for both mother and child is considerably less favorable 
than in normal labor, since difficult operative delivery is often necessary. 
^Moreover, the rarity of the condition makes it liable to be overlooked. 

Treatment. — =For delay in the first stage the best treatment is version. 
Extraction of the after-coming head may prove difficult, since the foetus is 
usually large, but an attempt to drag the large head through the pelvis by 
its longest diameter with the forceps can only deserve condemnation. 

If the head passes the brim it is best to pursue an expectant policy 
as long as seems consistent with the interests of the patient. Now and 
then natural delivery will occur contrary to all expectations. If it be- 
comes evident that the efforts of nature are unavailing the forceps should 
be applied, though an effort to flex the head, thus converting it into an 
occiput presentation, or if this fails to extend it and thus convert it into 
one of the face, may be tried. It should be remembered that the con- 
figuration of the head, the increase in its vertical diameter, makes it appear 
that the head is much lower than is really the case. This sometimes 
tempts the incautious operator to apply the forceps too soon, and perhaps 
with disastrous results. 

In operating with the forceps the axis-traction model should be used, 
since the greatest diameter of the head is always higher than it appears 
to be. Whether the operation be forceps or version, if the child is dead 
craniotomy should be performed. 

In the case of a viable child, pubiotomy and symphysiotomy have been 
advocated and performed. Pinard prefers the Caesarean section. To my 
mind, in view of the long diameter that must traverse the birth canal, and 
consequent danger of severe laceration of the soft parts, Caesarean section 
followed by hysterectomy, if infection seems probable, is to be preferred. 



CHAPTER XX 

FETAL MORTALITY IN LABOR. AN IMPORTANT BUT 
NEGLECTED SUBJECT. CAUSES, DIAGNOSIS, PREVEN- 
TION AND TREATMENT OF FETAL ASPHYXIA. PRO- 
LAPSE OF THE CORD 

The practice of obstetrics differs from that of general medicine and 
surgery and from that of the other speciakies in many ways, but in no 
way, 1 think, is the dift"erence more marked than in the fact that the 
obstetrician has under his immediate and personal care two patients at 
one and the same time. This fact is often ignored, and the result is a 
deplorable increase in fetal mortality. It is, indeed, a sad reflection that 
many an unborn child, whose potential usefulness and whose capacity for 
happiness we may not know, is lost for lack of a few simple precautions. 

Etiology. — It is neither necessary nor possible that every obstetrician 
should be an accomplished embryologist and physiologist, but it is necessary 
that he should be familiar with the various causes of fetal asphyxia and 
with the mechanism of its production. 

The causes may be of either maternal or fetal origin. One would 
naturally suppose that the oxygen supply of the foetus depends upon the 
quality of the mother's blood, but this is by no means always the case. 
How often do wx see strong and vigorous children born of delicate and 
ansemic mothers. Such instances are often observed in advanced tuber- 
culosis. The child seems to take what it needs, and the mother must get 
along with the rest. When, however, the mother is suddenly deprived of 
oxygen, as in cardiac or pulmonary disease with grave cyanosis, fetal 
asphyxia is rapidly developed. 

Fetal Causes. — Among the causes which may be traced to the foetus 
or its appendages are prolapse of the cord, not forgetting the concealed 
form, separation of the placenta, placental apoplexies, etc. 

Faulty Operative Technic. — Unfortunately there are many cases 
which must be referred neither to the mother nor to the foetus, but to the 
operator. Faulty technic in the forceps operation and version, and par- 
ticularly in the delivery of the after-coming head, are common causes of 
asphyxia and the reader will do well to reread and carefully consider the 
sections treating of these subjects. It cannot be denied that they often 
receive too little attention. As we shall see elsewhere the misuse of 
anaesthetic agents, e.g., chloroform, ether, nitrous oxide, morphine and 
hyoscine, etc., may result disastrously. 

Of all causes, however, that of delayed labor, and especially of delayed 
second stage, is the most frequent. Of this, too, I have frequently spoken. 
It is strange that, in the past, prolapse of the cord, a dramatic accident 
404 



FETAL ^lORTALITY IN LABOR 405 

of rare occurrence, has received so much more attention as a cause of fetal 
asphyxia than delayed labor, which is its most common cause. 

AMiy does delayed labor result in fetal asphyxia ? During the uterine 
contractions, and particularly after the rupture of the membranes, the 
uterine interior is diminished in area, and with it, of course, the placental 
site. Thus the blood supply to the foetus is diminished and with it the 
oxygen supply. This, it is true, is of theoretical rather than practical im- 
portance during the first stage, but after the rupture of the membranes the 
diminution in area is considerable, and to this is added the factor of direct 
pressure upon the foetus. The fluid medium which has hitherto protected 
it is no longer present. It is true that the foetus often withstands the 
process for an astonishingly long time, but it is not safe to rely upon this. 

If the head is large or the pelvis small, there is added the factor of 
cerebral pressure which may so irritate the vagus as to excite premature 
inspirations. 

Asphyxia Neonatorum 

Mechanism. — AMiat is meant by this term? With the complete separa- 
tion between mother and child which occurs at birth the blood supply from 
the mother is, of course, cut off and with this the fetal oxygen supply. The 
accumulation of carbon dioxide in the fetal blood irritates the respiratory 
centre in the medulla and this is ordinarily the cause of the first inspiration. 

But as we have already seen there are many conditions which may 
cause carbon dioxide poisoning in the unborn foetus. All these causative 
factors act primarily in the same way, i.e., by diminishing the amount 
of oxygen in the fetal blood. The accumulation of carbon dioxide irritates 
the respiratory centre in the medulla, causing premature inspiratory efforts, 
but the foetus in utcro can find no oxygen in its surroundings. In other 
cases inspiratory efforts are the results of direct pressure, e.g., in pelvic 
contraction or in forceps operations. 

Vvdiatever the cause, the results are disastrous. The foetus in iitero 
finds no oxygen in its surroundings. With each inspiration amniotic fluid, 
blood or mucus is drawn into the air passages. The expansion of the 
thorax opens up the pulmonary circulation, and as a result part of the 
blood which should flow from the right ventricle into the aorta is diverted, 
thus lowering the pressure in the umbilical artery and still further 
diminishing the oxygen supply (Bumm). 

Diagnosis. — Whenever any of the above-mentioned causes are present 
special caution is necessary, and in no case whatever, even in those to all 
appearances perfectly normal, should the condition of the foetus escape 
careful study, since experience has taught us that fetal asphyxia occasion- 
ally occurs in cases in which there is apparently no reason whatever to 
expect it. I do not mean, of course, that it can always be prevented in these 
cases, but something may possibly be done. At the worst the physician will 
be conscious that he has not neglected his duty and his patients will have 



406 PATHOLOGY OF PREGNANCY AND LABOR 

no just cause of complaint. It follows then that every case of labor should 
be studied with reference to the question of danger to the foetus. To wait 
until after delivery and then speculate as to the cause of the sad result is 
the height of folly. 

\Miat are the indications of impending asphyxia of the foetus, the 
immediate indications? 

By far the most important are to be found by the auscultation of the 
fetal heart. Let me repeat here, for the sake of emphasis, that every one 
who proposes to practise obstetrics should become familiar with the fetal 
heart-sounds in both normal and abnormal positions. As we already 
know, the fetal heart-sounds diminish in rate during uterine contractions, 
only to resume their normal rate during the intervals. When, however, the 
sounds are reduced to one hundred per minute or less, and this rate con- 
tinues during the intervals between the contractions, the fcetus is to be 
regarded as in serious danger and delivery should be completed if this can 
be done without special risk to the mother. If no relief is afforded, the 
sounds become still slower and at the same time markedly irregular. This 
indicates that the foetus is in great danger but not necessarily altogether 
beyond hope. If, how^ever, the condition remains unrelieved the heart- 
sounds become feeble and very rapid, or perhaps quite uncountable and 
fetal death soon follows. 

But there are other signs of danger to the foetus ; less reliable, it is 
true, but still not to be neglected. Of these perhaps the most significant 
is the passage of meconium, the result of the paralysis of sphincters 
resulting from profound asphyxia. In breech presentations or in trans- 
verse positions it has no special meaning. In these cases it is simply the 
result of mechanical pressure. A typical instance is found in breech 
presentation, of which it is a constant accompaniment. In vertex presenta- 
tions it is a sign of bad omen and, if the head is within easy reach, an 
indication for immediate delivery. It is possible, how^ever, for the foetus 
to pass meconium in iitero. Therefore the fetal heart should be auscul- 
tated at once while preparations are being made for delivery. If a trained 
observer recognizes that the sounds are normal in every respect, delivery 
may be delayed ; not otherwise. The fetal heart-sounds, however, should 
be carefully and constantly watched for the balance of the second stage. 

Cessation of fetal movements is of less significance after the beginning 
of labor than before. It is common for fetal movements to cease, or at 
least not to be noticed by the mother, after labor begins. On the other 
hand, unusually active movements of the foetus are to be regarded with 
suspicion. Nurses and bystanders often regard such movements as indica- 
tive of unusual strength and vitality on the part of the foetus, but they are 
only too often the result of the convulsions of asphyxia. 

In breech presentation, or during the extraction of the after-coming 
head in version, one can sometimes see the movements of the chest that 
accompany premature inspirations. 



FETAL ^lORTALITY IN LABOR 407 

Varieties. — Two varieties of asphyxia are usually recognized, asphyxia 
li\-ida and asphyxia pallida. The first is often called blue asphyxia. The 
second pale asphyxia. Their clinical characteristics soon become familiar 
to every practitioner. 

In the first the surface is congested and the whole body, especially the 
face, of a livid bluish hue. The heart and umbilical arteries pulsate slowly 
but strongly. The child may not breathe at first, but responds to peripheral 
irritation, e.g., a dash of cold water or a few drops of ether poured upon 
the chest. 

In asphyxia pallida conditions are for the most part reversed. The 
arms and legs hang limply, the head drops back, and the mouth is open. 
The skin is very waxy, and the child looks as though it had had a severe 
hemorrhage. ^lany writers state that the pulse is rapid and weak, appar- 
ently thinking that under the circumstances it ought to be. In my experi- 
ence it is vers- slow, often not over ten or fifteen per minute, sometimes even 
less. 

Long ago I learned to recognize a third variety. True, it is only a 
transition stage between the two, but it is highly important from the 
stand-point of prognosis and treatment. In this variety the child has most 
of the symptoms of asphyxia pallida, but there is still some little congestion 
of the face. Response to peripheral irritation is not entirely lost, and in 
my experience can usually be evoked by tongue traction. 

It is impossible to mistake the livid for the pallid asphyxia. Indeed, 
as soon as the head is born the diagnosis can be made, and the experienced 
operator rejoices at this time if, after a difficult delivery, he notes lividity 
of the face, instead of the dreaded pallor, which always indicates that the 
child is in extreme peril. 

Preventive Treatment. — The very general neglect of the preventive 
treatment of fetal asphyxia is a reproach to the practice of medicine. Too 
many pay little attention and give little thought to the welfare of the 
unborn child. It is usually taken for granted that the child will eventually 
be born per vias natiirales, probably alive, possibly dead. In the latter case 
the result is too often regarded as a dispensation of Providence, or at all 
events as something beyond the power of the physician to prevent. Quite 
the contrary is the case. Even a superficial study of the matter will suffice 
to show that it is rich in possibilities for good. 

It cannot be too often repeated that asphyxia of the new-born is but an 
advanced stage of a process that begins before delivery, sometimes long 
before delivery, and that it is, in most cases, preventable. The whole man- 
agement of labor and the technic of the various operations should be 
studied from this point of view, and I have striven to emphasize the details 
through this work. Of special importance are the limitation of the amount 
of the auccsthetic, the avoidance of forceps compression and the prompt 
and skilful delivery of the after-coming head. The time to think of and 
to prepare for all these things is while the child is still alive and the fetal 



408 PATHOLOGY OF PREGNANCY AND LABOR 

heart is still good. He who does not attend to these matters is sure to meet 
with disaster '' in the long run." 

I have referred elsewhere to certain studies of my own in connection 
with oxygen in the treatment of eclampsia and in the toxaemia of preg- 
nancy, and, without wishing to attach undue importance to my own work, 
I may perhaps venture here to call attention to certain immediate effects 
upon the unborn child, of oxygen adDiiiiistered to the mother, which were 
observed in the course of my experiments at the New York City Hospital, 
and which had, I think, up to that time escaped attention. 

In the first place, the inhalation of oxygen by the mother appears ta 
increase the rapidity of the fetal heart. I have before me the notes of 
eleven tests made at the City Hospital. Each test consisted in the inhala- 
tion of oxygen for five minutes by a pregnant woman at or near term, the 
fetal heart being counted before and after inhalation. Fetal movements 
were also observed and uterine contractions noted. In order to eliminate 
the personal element I did not do the counting myself, but entrusted the 
task to one of my assistants. The rapidity of the fetal heart-sounds was 
increased in every case. In two cases the increase was so small as to be 
practically negligible, two and four beats respectively ; in a third it was 
eight beats, and in the remainder it Avas from sixteen to twenty-five beats. 
The average increase was about fifteen beats. The real increase was some- 
what greater than is here indicated, since the inhalation of oxygen appears 
to excite uterine contractions, and in at least four cases the counting was 
done during a contraction. It is a matter of every-day experience that 
the fetal heart beats more slowly during a contraction. 

Another new and curious fact noted during these experiments is that 
oxygen increases the frequency and activity of the fetal movements. Out 
of nine tests it w^as found that the fetal movements were increased in five. 
In three of these they w^ere marked simply " increased " and in the remain- 
ing two " markedly increased." In the case of one patient near term and 
since delivered, the foetus underwent remarkable contortions, but without 
harm. 

Why do the fetal heart-sounds become more rapid, and the fetal move- 
ments more active, under the influence of oxygen? Certainly not because 
of a general stimulation of the maternal organism. Drugs given by the 
mouth or hypodermically do not ordinarily affect the fetal heart. The 
fetal and maternal circulations, however, are really one, and if oxygen 
enters into chemical combination with the maternal blood, how can the 
blood of the foetus escape its influence ? 

Now if we can administer oxygen to the foetus, and if the foetus re- 
sponds symptomatically to that administration, is it not plain that we can 
do much in the prevention and treatment of antenatal asphyxia? The 
normal slowing of the fetal heart during contractions usually does no 
harm, but if the labor is much prolonged or if the contractions become 
tetanic in character, the foetus will sooner or later show the effect of the 



FETAL ^lORTALITY IN LABOR 409 

diminished supply of oxygen. During a uterine contraction there is, of 
course, a corresponding diminution of the placental area. The foetus thus 
receiA'CS less blood and consequently less oxygen. In our experiments at 
the City Hospital the fetal heart-sounds were increased in frequency during 
the contractions. Therefore it would seem a wise precaution to ad- 
minister oxygen to the mother in cases of prolonged second stage, in 
partial separation of the placenta, or whenever slowness or irregularity of 
the fetal heart-sounds indicates impending asphyxia. 

I am aware that there are many sources of error in counting the fetal 
heart, but the fact that in eleven cases an increase was noted in every case, 
that the average increase was about fifteen beats per minute, and that in 
some cases it was as high as twenty-five beats per minute, and that in a 
large number of cases the fetal movements were increased, sometimes 
markedly so, seems to indicate that the inhalation of oxygen by the mother 
is not without its effect upon the foetus. 

In two subsequent tests conducted in the same manner the heart rate 
was increased ten beats per minute and fetal movements were observed. 

Shortly after this, one of my house surgeons, whose name I do not now 
recall, had an opportunity of witnessing the stimulating efifect of oxygen 
upon the foetus during a difficult version. With his hand in the uterus he 
distinctly felt fetal movements immediately following the administration of 
oxygen to the mother. 

Since the above experiments were made I have continued the use of 
oxygen in difficult labor and in obstetric operations with a view to prevent- 
ing prenatal asphyxia, and with apparently favorable results. Several of 
my colleagues have had the same experience. 

On the basis of these experiments I have been in the habit of advising 
that whatever anaesthetic is used in obstetric operations be given with 
a large admixture of oxygen in order to minimize the danger of fetal 
asphyxia from the anaesthetic as well as from causes incident to the 
operation itself. 

At the present time there is in one of the wards of the City Maternity 
a patient suffering from placenta praevia. She was an ambulance case, had 
been bleeding for some time before admission, and was beginning to show 
symptoms of acute anaemia. The cervix barely admitted three fingers: 
A foot was brought down and traction upon this brought the half breech 
into the cervix, which, however, was hard and not very dilatable. The 
bleeding now ceased but forcible extraction or other operative procedure 
was not deemed advisable. The fetal heart rate was 136. Oxygen was 
administered, whereupon the rate rose at once to 160. About forty-five 
minutes elapsed between the bringing down of the breech and the delivery 
of the head. During this time moderate traction was made upon the fetal 
leg in order to control the bleeding. Meanwhile oxygen was administered 
and the fetal heart was constantly watched. Shortly before delivery it 
became very rapid (190) but remained of good quality. The child was in 
excellent condition and no measures of resuscitation were required. 



410 PATHOLOGY OF PREGNANCY AND LABOR 

Another patient, also in the hospital at this writing, was admitted suffer- 
ing from profound toxaemia. The usual treatment, rest in bed, milk diet, 
catharsis, etc., was supplemented by frequent inhalations of oxygen and 
marked improvement followed. The treatment, however, including the 
inhalations, was continued. At the end of a week I questioned her as to 
the immediate effects of the inhalations. In reply, she stated among other 
things that during or after these she '' felt the baby kicking." I had said 
nothing about the child nor was I thinking of the effect of oxygen upon the 
foetus at the time. 

This unsolicited and unsuggested testimony of the patient, a very in- 
telligent woman, confirming as it does the observations mentioned above. 
is to my mind highly significant. 

I desire to emphasize the fact that in order to eliminate the personal 
element I did not do the counting of the fetal heart myself. It was done 
in every instance by a member of the house staff, but not always by the same 
member. The fetal movements, too, were observed by different members 
of the house staff, with the single exception of the case referred to above, 
in which they were observed many times by the patient herself. 

Another patient, now under treatment in a private hospital, gave similar 
testimony, and adds the interesting information that wdien the oxygen is 
given by one of her nurses, who is evidently a convert to this method of 
treatment, the effect upon the foetus is much more marked than when it is 
given by the other nurse, who is less prodigal in its use and is evidently 
working in the interest of hospital economy. 

I have no further hesitation in making the claim that it has been 
definitely proven that we can administer oxygen to the foetus, and that the 
foetus responds to its administration. 

Curative Treatment. — In every labor case, and especially in every 
operative case, everything necessary for the resuscitation of the child 
should be provided in advance. The requisites are few and inexpensive. 
Their absence may mean irremediable harm. They include two large 
bowls, one for hot the other for cold water, a tongue forceps for tongue 
traction, and a laryngeal tube for aspirating mucus from the air-passages 
and for insufflation. The traditional catheter so often advised is an 
abomination. Even an expert intubator will be unable to achieve results 
Avith it. Oxygen should be at hand if obtainable ; also a pulmotor. 

In the first place, be sure that the child is asphyxiated before insti- 
tuting radical measures of treatment. After prolonged operations, chil- 
dren are often born profoundly narcotized by the aucesthetic circulating 
in the mother's blood. These children, although breathing regularly, do 
not cry, and for this reason are often subjected to manipulations which 
are unnecessary and perhaps injurious. 

It is important to remember that the treatment varies with the type 
of asphyxia. Measures that are appropriate in the severe forms are, to 
say the least, unnecessary in the mild form (Figs. 244 and 245). 



FETAL ^lORTALITY IN LABOR 



411 



In the ordinary type of asphyxia hvida, simple reflex stimulation 
suffices. The child is held by the feet, the head hanging- down. This 
position helps by gravity to dislodge fluid from the air passages and is 




N.^ V 





Fig. 244. — Treatment of case of asphyxia livida. 



aided by rhythmical compression of the chest. The cerebral congestion 
induced is of itself beneficial. The little finger wrapped in gauze clears 
the mouth and pharynx of mucus. The nares may be effectually emptied 



412 



PATHOLOGY OF PREGNANCY AND LABOR 



H 



by blowing into the child's mouth through a piece of gauze. Very often 
the contact of the finger with the fauces is sufficient to excite inspiration. 
If not. cold water or a little ether may be dashed upon the chest. These 




M 



Fig. 245. — Same with rhythmical compression of chest. 



measures are usually promptly successful. If respiration is delayed, how- 
ever, the child should be immersed alternately in warm and in very cold 
water. This old-fashioned measure often succeeds when previous methods 



FETAL MORTALITY IN LABOR 



413 



have failed. It may be ccmbined with the Harvie Dew method of 
respiration, which in my hands has proven very satisfactory. If the case is 
still refractorv, the child should be immersed in warm water, and 



^' 





Pig. 246. — Tongue traction. An invaluable resource in asphyxia neonatorum. 

wrapped in warm blankets and tongue traction tried (Fig. 246). In this 
procedure the tongue is seized with a pair of tongue forceps and drawn 
out until the operator meets with distinct resistance, held in this position 
for a second or two and then allowed to recede. This is repeated but not 



414 PATHOLOGY OF PREGNANCY AND LABOR 

too rapidly ; about fifteen times a minute. A'ery often the child gasps after 
the first traction and after each succeeding one. If a tongue forceps is not 
at hand a tenaculum may be used. I have several times been obliged to 
resort to this and have never found that the tiny pricks in the tongue 
did any harm. In my hands tongue traction has proven more valuable^ 
by far, than any other method of peripheral irritation, more valuable, 
indeed, than artificial respiration, and if it evokes no response I always 
feel that the prognosis is grave. It is especially valuable in those cases 
of intermediate type approaching closely the true asphyxia pallida. Most 
of the reported cures of asphyxia pallida are of this kind. 

The student naturally asks, " How is respiration furthered by making 
traction upon the tongue ? " The explanation is as follows. The pull 
upon the base of the tongue irritates the superior laryngeal and other 
nerves and this irritation is transmitted reflexly to the phrenic nerves. 



^^ '^Sv 



„Xa**«W«?-*«' 



Fig. 247. — Introduction of laryngeal tube. 



which govern the diaphragm and intercostal muscles. As is well known, 
tongue traction is one of the best means of reestablishing suspended 
animation in chloroform poisoning. The efficacy of the procedure is 
increased by combining it with oxygen inhalation. 

In well-marked asphyxia pallida there is no response to peripheral 
irritation, not even to tongue traction. The medulla no longer reacts to 
the usual methods of stimulation. The air passages are full of mucus, 
even to the smaller bronchi. The problem is to get oxygen into the lungs. 
But first the mucus must, as far as possible, be removed. How shall this 
be accomplished? 

The pharynx and nostrils are first cleared as already described. The 
next step is the passage of the tube into the larynx. The index finger of 
the left hand locates the lar3mgeal opening by means of the arv^tenoid 
cartilages, which are easily felt, and its radial border serves as a guide for 
the tube, which is passed with the other hand. This manoeuvre is not 



FETAL MORTALITY IN LABOR 



415 



always easy, and I would strongly advise those of my readers who are not 
familiar with the technic to practise it upon the cadaver whenever the 
opportunity otters (Figs. 247 and 248). 





XiM^^m^-'f^'Ji^mi" 




■m.M 



Fig. 248. — Method of using the laryngeal tube. 



When the tube has entered the trachea, the fact can be determined by 
giving its tip slight lateral movements (Jeannin). These are easily ap- 
preciated by the finger applied externally. The operator then places a few 
layers of gauze over the outer end of the tube, sucks the contents of the 



416 



PATHOLOGY OF PREGXAXCY AND LABOR 



trachea into the tube, removes the tube, and blows out the contents. This 
is repeated until the trachea is empty. 

The tube being replaced, the operator, having expelled the residual air 
from his lungs, blows a little air very gently into the tube. In order that 
the air may contain as much oxygen as possible, he should take only a 
superficial inspiration before blowing into the tube. If air enters, the lungs 




Fig. 249. — Holden's oxygen insufflation. 

will be observed to expand. The chest is then lightly compressed with the 
hand, thus favoring expiration. This manoeuvre is repeated from six 
to eight times a minute. 

]\Iouth to mouth insufflation, while not as direct or as effectual as 
insufflation through the tube, has the advantage of simplicity and ease of 
performance. Xo instruments are required and it can be performed by 
any intelligent layman. The child lies on its back with head moderately 
extended. The operator blows into the child's mouth through a piece of 



FETAL MORTALITY IN LABOR 



417 



gauze and with the precautions above mentioned. Doubtless much of the 
air enters the stomach rather than the hmgs. An effort is made to prevent 
this by gentle pressure with one hand over the epigastric region. Expira- 
tion is encouraged by compressing the chest wall with the hand. 




Fig. 250. — Harvie Dew's method of artificial respiration; inspiration. 

Holden's method of direct oxygen insufflation is in my opinion the best 

of all methods of artificial respiration. It has been extensively used in the 

clinic of Polak, from whom this description is taken. '* The child is laid 

on its back, in a bath of warm water, with the head partially extended, to 

27 



418 



PATHOLOGY OF PREGXA^XY AND LABOR 



straighten the trachea. The hand is placed under the shoulders and the 
neck allowed to rest in the cleft between thumb and index finger, which 
steadies the head. A close-fitting mouthpiece, or small rubber funnel con- 
nected by rubber tubing to an oxygen tank, is then firmly placed over the 




Fig. 251. — Harvie Dew's method of artificial respiration; expiration. 

child's mouth and the oxygen turned on. Almost immediately the rate of 
heart-beat will be increased and the cyanosis of the skin changed to pink, 
while upward stroking of the chest wall along the long thoracic nerve will 
cause the child to make inspiratory efiforts " fFis^. 249). 

The much vaunted and widely advertised pulmotor is perhaps of spec- 



FETAL ^lORTALITY IN LABOR 419 

tacular effect rather than of real advantage. Aliich of the air supposed to 
be inspired escapes about the mouthpiece and a large part of the balance 
enters the stomach rather than the lungs. In mouth to^ mouth insufflation 
the air, having already been breathed once, is more or less vitiated. 
Holden's method is practically the use of the pulmotor except that oxygen 
is used instead of atmospheric air. Bearing in mind the relatively small 
quantity that enters the lungs under the older method the advantages of 
the Holden method are obvious. L^n fortunately the facilities for its use 
are not usually found outside of hospitals. 

Engelman has recently devised an apparatus for giving oxygen through 
the tracheal tube. 

It is very generally taken for '^ 

granted that artificial respiration 
plays the principal role in the 
scientific treatment of asphyxia 
neonatorum. As a matter of 
fact this is by no means the case. 
As a reflex excitant of inspira- 
tion it is inferior to tongue trac- 
tion and to the alternate use of 
hot and cold water, while for 
keeping up the oxygenation of 
the blood it does not serve as 
Avell as oxygen insufflation, or 
insufflation, through the laryn- 
geal tube. Certain forms, how- 
ever, do aid materially in bring- 
ing about the expulsion, empty- /* 
ing the air passages of mucus. |.,' ^ 
Of the various methods of - ^, • 
artificial respiration I prefer '^L 
that of Harvie Dew, which 
affords very complete expansion 
and contraction of the thoracic 
cavity, more, I think, than most 
other methods, permits the very mmtMiiiiiiii 
frequent immersion of the ^,^ t, t, -i • .1 , r 

.^ . tiG. 252. — Prochownik s method of rtsuscitalion. 

child s body m warm water, and 

as can be easily demonstrated is very effectual in the removal of fluid from 
the air passages. This method, which can be more easily illustrated than 
described, is well shown in Figs. 250 and 251. 

Another good method is that of Prochownik, in which the child is sus- 
pended with the head downward and the chest compressed at intervals. 
Extension of the head is favored by allowing the forehead to rest lightly 
upon a folded sheet, as shown in Fig. 252. This method has the advantages 




420 



PATHOLOGY OF PREGNANCY AND LABOR 



of inverted suspension and involves no traumatism whatever. It also 
favors the expulsion of fluids from the trachea. It is especially valuable in 
the case of exhausted or premature children. 





Fig. 233. — Sylvester's method; inspiration. 



The well-known method of Sylvester, familiar to all life savers and 
students of " first aid," is of little use in the new-born, since the bones and 
their cartilaginous attachments are not yet strong enough to serve as 



FETAL MORTALITY IN LABOR 



421 



media for the expansion of the thorax. Nor is it very effectual in emptying 
the air passages (Figs. 253, 254. and 255). 

The classical " swingings " of Schultze, which I have often tried but 




m^ 




Fig. 254. — Sylvester's method; expiration. 



now seldom use, are unnecessary in the milder cases and useless in the very 
serious ones. 

This is the conclusion of Fabre, Ayers, and many others. That they are 



422 



PATHOLOGY OF PREGNANCY AND LABOR 



mechanically efficient can be readily shown, but that they are often dan- 
g-erous is equally evident. They are quite inapplicable in the case of pre- 
mature children, and should, of course, never be used in cases of fracture. 








»;'-« £, 

'^^k-^ 
^CV 



'%.rtJ 




Fig. 255. — Sylvester's method with tongue traction. 



Their extensive use in the past, however, together with the fact that they 
still occupy a prominent place in the literature of the subject, not to speak 
of their occasional mention in examination papers, makes it necessary that 



FETAL MORTALITY L\ LABOR 



423 



the student should know something about them. Figs. 256 and 257 show 
the method of their employment better than it can be done by a printed 
description. 



^^v>^ 



. \ 



\ 





Fig. 256. — Schultzes method; inspiration. 

Many writers, especially upon the continent of Europe, forbid the use 
of any form of artificial respiration until the trachea has been cleared by 
insufflation. This, of course, is theoretically correct, but to attempt to 
carry it out in practice is, I think, to go too far. Such an attempt assumes 



424 



PATHOLOGY OF PREGNANCY AND LABOR 



that every obstetrician is a good intubator, that intubation is ahvays easy, 
and that the resuks of insufflation are always satisfactory. As a matter 
of fact the most effectual methods of artificial respiration, those for example 




Fig. 257. — Schultze's method; expiration. 

of Schultze, Prochownik, and Harvne Dew, act chiefly by mechanically 
removing inspired fluids. Moreover, all theoretical considerations aside, 
experience shows that in livid or congestive asphyxia these methods are 
often followed by good results. I am therefore in the habit of advising 



FETAL MORTALITY IN LABOR 425 

artificial respiration in those cases in which with congestive asphyxia there 
is evidence of fluid in the air passages, though more with the idea of empty- 
ing the air passages than of stimulating inspiration, nor should it be con- 
tinued too long ; for the latter purpose peripheral stimulation in the form 
of the hot and cold plunge or of tongue traction. In pallid asphyxia 
insufflation in some form should always come first. In these there have 
usually been many inspirations in utero and the larynx and smaller bronchi 
are full of fluids which can hardly be completely removed by any method 
of artificial respiration. 

\Miatever method of resuscitation be employed, as soon as respiration 
has been established and improvement, though slow, is progressive, the 
child should be wrapped in warm blankets and let alone, further handling 
being avoided. One thing aids, however, in bringing about rapid recovery 
— the inhalation of oxygen. Of course, if there are no respiratory move- 
ments oxygen, except by insufflation, can do no good, but in those cases in 
which inspirations are shallow and infrequent prompt results are sometimes 
seen. The action of oxygen upon the foetus is very prompt and certain. 

The operator should not forget that his duty at this time is not only to 
save the child from immediate death from asphyxia but from subsequent 
death from atalectasis. Llany children while appearing to be strong and in 
fairly good condition yet retain much mucus in the air passages. It is in 
these cases that artificial respiration has seemed to do most good and 
those methods which favor the removal of mucus from the air passages. 

Deeply asphyxiated children though revived are by no means out of 
danger. Cerebral compression or hemorrhage may have left inefifaceable 
marks, or the child may die of atalectasis within a day or two. Therefore 
these children should be carefully watched. All tight clothing or bandages 
which may interfere with free expansion of the thorax should be tabooed 
(Jeannin). The inspiratory reflex should be stimulated, so that the child 
cries vigorously, insufflation repeated if necessary, and above all oxygen 
should be administered. 

For the first two or three days the prognosis should always be guarded 
and provisional. 

In most discussions of this subject one finds nothing about the treatment 
of asphyxia in premature children and the reader is left to infer that it is 
the same as in robust infants born at full term. This, it seems, is a grave 
error. As a rule the principal trouble with these children is debility 
rather than respiratory obstruction. The rougher methods and particularly 
" swingings " of Schultze should be avoided. Bearing in mind the fact 
that the heat-producing mechanism in these cases is defective, the judicious 
physician will employ for the most part those which can be practised with 
the child wholly or partly immersed in warm water. Tongue traction has 
seemed to me less beneficial in these cases than in full term children, thoueh 
it should always be tried if other methods fail. Oxygen I believe to be of 
special value in these cases. 



426 PATHOLOGY OF PREGXAXCY AND LABOR 

Before artificial respiration, clear the upper and if necessary the lower 
air passages, thus avoiding inspiration of mucus. As soon as respiratory 
movements are regular and little or no mucus is in the air passages the 
child should be kept warm and quiet and let alone. 

Two things more. Loss of bodily heat is most depressing to the 
new-born. ^Manipulations should be carried on as far as possible with 
the child in the warm bath or wrapped up in warm blankets. Loss of heat 
by evaporation is rapid. This should be remembered when practising the 
different methods of artificial respiration. 

L^nnecessary manipulations should be avoided. Slapping the buttocks 
and similar methods are quite unnecessary and have often been known to 
cause serious injury. Rupture of the liver and of the suprarenal capsules 
has been noted. A dash of cold water or an instant's plunge in the cold 
bath accomplishes the same result and with no harm. 

Summary. — Clear and correct descriptions of the treatment of fetal 
asphyxia are rare, and some writers seem to have no positive opinions at 
all on the subject. A'ery often a medley of methods is presented with no 
reference to their relative importance or to the order in which they should 
be used. The result is great confusion in the mind of the student or 
young practitioner. Therefore a brief summary of the main things to be 
remembered may not be out of place. 

Congestive Asphyxia. — This is the usual or milder form. Suspend 
the child by the feet and cleanse the pharynx and nostrils as already de- 
scribed. Then tie the cord. A dash of cold water or ether upon the 
chest usually suffices to cause inspiration, the child cries vigorously, and no 
further treatment is required. If there is no response to this treatment, use 
the hot and cold water dip alternately, and practise tongue traction. If 
there is no response to tongue traction properly performed the prognosis 
is grave. The case is one of the border line variety or is rapidly becoming 
one of pallid asphyxia. 

Pallid Asphyxia. — Here the time for peripheral irritation has passed. 
The medulla no longer reacts. Aspiration of mucus from the trachea by 
the tracheal tube and insufflation by the same instrument or Holden's 
oxygen insufflation offers a hope of success; a rather forlorn hope, it is 
true, but one which should not be given up as long as any heart-beat can 
be detected. 

Prolapse of the Cord 

By this term is usually meant the descent of a loop of the cord in 
advance of the presentnig part. In this case the cord is plainly perceptible 
to sight and touch. There is another form, however, usually neglected or 
ignored, but of the greatest importance, in which the cord descends far 
enough to be compressed by the presenting part but not far enough to be 
seen or felt by the usual methods of examination. There are then in reality 
two kinds of prolapse, visible and concealed. 



FETAL ^lORTALITY IN LABOR 427 

Ordinarily the descent of the cord is prevented by the presence of the 
smooth globular vertex. \Mien, however, the presenting part does not 
completely fill the lower uterine segment the natural safeguard is absent, 
and the escape of a loop of cord an easy matter. Hence it is easy to under- 
stand why prolapse of the cord is often found in the case of certain 
malpositions and malpresentations, e.g., in breech, face, and transverse 
cases and when a tumor or a pendulous abdomen, or a contracted pelvic 
brim prevents the descent of the vertex. 

Predisposing causes are unusual length of the cord, and marginal inser- 
tion of the cord or low insertion of the placenta, both of which cause 
2. relative lengthening. 

AMiatever the ultimate cause prolapse is most likely to occur at the time 
of rupture of the membranes, especially if there is an abnormal quantity as 
in hydramnion, or if the patient happens to be standing at the time. . 

Diagnosis. — Prolapse of the cord can hardly be mistaken for anything 
except prolapse of a loop of intestine through a rent in the uterine wall. 
In that case, however, pulsation is absent and the mesentery can be felt. 
Furthermore there will be a history of uterine traumatism. 

It is most important to determine whether the foetus is living and 
viable, for upon this the treatment depends. The necessity for this de- 
termination occurs much more frequently than does the necessity for the 
differentiation between prolapse of the cord and intestinal prolapse. Nor 
should the attendant forget to inquire as to the period of pregnancy. I was 
once called in great haste to see a case of prolapse of the cord. There was 
no doubt as to the diagnosis, since a loop of cord protruded from the vulva. 
The abdominal tumor, however, did not seem to correspond to that of full 
term and careful questioning elicited the fact that pregnancy was of less 
than seven months' duration. In some cases the best thing is to do nothing. 

The diagnosis of the death of the child, however, is not always easy. 
The mere absence of pulsation in the cord is not always sufficient, as ex 
perience has shown. If, however, it is accompanied by cessation of the 
fetal heart-sounds, as recognized by a competent examiner, the diagnosis 
becomes more positive in some cases, e.g., in those in which there has 
l)een long compression or in which all doubt is absent, and these are the most 
satisfactory with which to deal. 

Prognosis. — There is no danger to the mother in prolapse of the cord 
per se, but there may be in the operations proposed and carried out for its 
relief. The fetal prognosis varies with the attendant circumstances. In 
liead presentations, however, it is always very grave, probably under 
present methods 50 per cent, or more. More so when the prolapse is 
anterior than when posterior, where there is more room. The earlier the 
period of labor the worse the prognosis. It is made much more grave by 
rupture of the membranes. In breech and shoulder presentations it does 
not add greatly to the danger. 

This is one of the most serious emergencies of obstetric practice. 



428 PATHOLOGY OF PREGNANCY AND LABOR 

While it is not very common it is just as likely to happen in the practice 
of the beginner as in the hospital operating room. The life of the child 
is at stake and as a rule there is no time to be lost. 

Let us take first what is perhaps the most common case. The cervix 
is fully dilated, or at all events will admit two or three fingers, and is soft 
and easily dilatable. The prolapse has been determined during an ex- 
amination made during labor. If under these circumstances the conditions 
are favorable for version and if the operator has attained some familiarity 
in its performance, and especially if he is skilled in the delivery of the after- 
coming head, version is, in my opinion, the best procedure, far better than 
repeated attempts to replace the cord, which after all may be unsuccessful. 
In performing version the operator is simply seeking to produce conditions 
which in prolapse of the cord are favorable. He is seeking to substitute 
for the round, hard head of the foetus so dangerous as a cord compressor, 
the soft irregular bulk of the breech, which in this respect has but little 
effect. The mortality in versions and in breech presentations is, it is true, 
considerably higher than in vertex presentations, but not nearly as high as 
in the latter presentation, when complicated by prolapse of the cord. 
But in these cases version, if it is to be performed at all, must be performed 
at once. Here it is true, only too often, that he who^ hesitates is lost. 

In most cases it is best for the child that immediate extraction should 
follow, since the child may have already sustained more or less injury. If, 
however, the cervix is hard and undilatable it may be necessary to delay in 
the interest of the mother. It is true that the condition of the child is not 
enviable, but it is less precarious than before. 

Treatment. — If the membranes have not ruptured the patient should 
be placed in the latero-prone position with the hips elevated upon a pillow 
or with the aid of a chair in the Trendelenburg position. The patient 
should be carefully watched, but unnecessary examinations should be 
avoided at this stage. Every effort should be made to preserve the mem- 
branes intact. If rupture can be postponed until the cervix is completely 
dilated the chances of saving the child are much enhanced and operative 
delivery much less dangerous to the mother. The fetal heart should be 
auscultated at frequent intervals. 

Before rupture of the membranes, then, there is little to be done. After 
their rupture an immediate investigation is necessary. The treatment now 
depends upon the condition of the cervix. 

If there is but slight dilatation, and especially if the cervical canal has 
not been effaced, those most interested should be consulted and the situation 
made plain to them. If the fetal heart-sounds are good there is every 
prospect of securing a living child by the Csesarean section, whereas by the 
usual methods of treatment the chances of its sur\'ival are slight. Then, 
too, we must not forget that pelvic contraction is one of the causes of 
prolapse of the cord. Of course, the operator must be competent and the 
surroundings favorable. 



FETAL MORTALITY IN LABOR 



429 



But suppose that this proposition is rejected, or that conditions forbid 
the Cesarean section. The cervix is hard and undilated, and perhaps the 
canal persists. These unwelcome and fortunately rare cases were formerly 
treated by the repositor, and nearly all of them were lost. A gauze tampon 
in the cer^'ix serves to prevent the descent of the cord, and to bring about 
dilatation of the cervix. A de Ribes bag accomplishes the same objects 
but requires more experience and facility in obstetric operating. 

An improvised repositor is shown in Fig. 258. It may be made from 
a hard rubber catheter or some similar instrument. The cord is caught 
within the loop and carried high above the point of pressure. The patient 
is kept in the Trendelenburg position for some time. The repositor may 
be left in iitero to be expelled with the pains. This ancient instrument, 
figured in all the text-books, has of late fallen largely into disuse. The 
cord is likely to be twisted or compressed and to come 
down again. Repeated efforts may cause premature 
inspirations with resulting fetal asphyxia, and the neces- 
sary intra-uterine manipulations increase the danger of 
infection. Where there is room the hand is a better 
repositor. However, in rare instances with narrow cer- 
vix and canal preserved, a repositor might be indicated. 

In the great majority of these cases, however, it 
would be better to use a de Ribes bag. With the patient 
in the Trendelenburg position, the largest bag that can 
be passed through the cervix is introduced and inflated. 
This is a distinctly modern and efficient method of 
treatment. The bag helps to keep the cord from descend- 
ing and furthers the dilatation of the cervix, thus help- 
ing to restore the conditions existing before rupture of 
the membranes. The process, however, requires con- 
siderable dexterity and constant supervision and there- 
fore as soon as there is sufficient room to perform 
podalic version it is wise to do so. 

As soon as the child has been turned and a foot brought down it is 
usually wise to complete delivery without delay since the child has perhaps 
already been more or less shocked. If, however, owing perhaps to an 
unyielding cervix or to the general condition of the mother, extraction 
cannot be immediately performed, the child is at least in a more favorable 
position than before. 

Lender these circumstances it is better, contrary to the usual rule, to 
bring down one foot rather than two, thus blocking up the pelvis more 
completely and tending to prevent further escape of the cord. The fetal 
heart should be narrowly watched. 

Some writers advise that the cord be carried up and attached to a 
leg of the foetus by means of the hand introduced into the uterus. This 
is about as much of an operation as is version and, in my opinion, should be 




Fig. 258. — Improvised 
repositor. 



430 PATHOLOGY OF PREGNANCY AND LABOR 

reserved for those cases in which version is likely to prove difficult, e.g., m 
which the patient is a primipara and the foetus overgrov^n. 

After all efforts at reposition the patient is placed for a time in the knee- 
elbow position and then for a time in the latero-prone position with the hips 
elevated. The patient should lie upon the side toward which the cord does 
not escape. The fetal heart should be auscultated at frequent intervals, 
during the balance of the labor. 

If the child is dead perforation should be done in order to save the 
mother unnecessary traumatism. 

Let us sum up the matter. 

If the membranes have not been ruptured they should be preserved 
as long as possible. 

If the membranes have been ruptured and the cervix is dilated or easily 
dilatable and other conditions are favorable version offers the best prospect 
of success. 

If, on the other hand, the cervix is not easily dilatable the cord should 
be replaced by the hand or by a repositor and prevented from falling by a 
gauze tampon or a de Ribes balloon, and by keeping the patient in the 
knee-chest or the Trendelenburg position. 

Concealed prolapse is likely to escape the notice of any except the most 
careful men and those who have attained some mastery of obstetric technic. 
Slowness or irregularity of the fetal heart, without apparent cause, occur- 
ring when the head is down in the pelvic cavity, and the heart sounds have 
previously been normal, and accompanied perhaps by a murmur, is highly 
suggestive. The same symptoms sometimes follow the application of the 
forceps, as is noted in the chapter on the forceps operation. If the hand is 
introduced into the vagina, and the fingers carried well up into the cervix 
the cord may be felt. The treatment is the application or reapplication of 
the forceps in such a way as to avoid compression of the cord if this has 
taken place. If compression cannot be avoided delivery should be as rapid 
as is safe. The operator, however, should remember that version is some- 
times practicable even when the head is low in the pelvis, and if not 
contra-indicated is preferable to much compression of the cord with the 
forceps. 



CHAPTER XXI 

LACERATIONS OF THE GENITAL TRACT DURING LABOR 

LACERATIONS OF THE PERINEUM AND VULVA. LACERATIONS OF THE 
VAGINA. LACERATIONS OF THE CERVIX. HEMATOMA. RUPTURE 
OF THE UTERUS. INVERSION OF THE UTERUS 

The Repair of Perineal Lacerations (Primary Perineorrhaphy) 

The subject of the repair of perineal lacerations is usually assigned to 
the pathology of obstetrics, but since these lacerations are so common, and 
their repair a necessary part of the conduct of many labors, especially first 
labors, I have thought it best in a practical work like this to include the 
whole subject in the consideration of the management of labor. I believe 
that the student and reader should be made to understand that the preven- 
tion and repair of all varieties of perineal laceration is an integral and 
indispensable part of said management. Certainly no man who is unable 
or unwilling to unite the ends of a divided rectal sphincter should desire 
to undertake the responsibility of managing a case of labor. In the chapter 
on normal labor we have considered the etiology and prevention of these 
injuries. Let us here take up briefly the question of their repair. 

As already stated the physician cannot always be blamed because his 
patient has a perineal tear. He should, however, and perhaps will, be 
blamed, if he makes no attempt at repairing the tear. Now and then it is 
true his patient may be in a condition of shock as the result of some grave 
operation, or may be suffering from the results of hemorrhage, and he may 
be quite right in assuming that she should be subjected to no further 
disturbance, but in these cases the repair can usually be made a day or two 
later. 

]\Iore important than the question of praise or blame is the fact that 
repair is necessary in the interests of the patient. Even tears of the first 
degree, if unrepaired, increase the risk of infection by presenting an area 
of raw surface at the vulva where postpartum contamination is most likely 
to occur. The " puerperal ulcer " of the older writers is simply a strepto- 
coccic membrane covering the site of an unhealed perineal tear. 

Tears of the second degree involving the perineal body and the vagina 
entail a train of consequences, immediate and remote, that soon become 
familiar to every observant physician ; gaping of the vaginal orifice, with 
partial descent of the vaginal walls, going on perhaps to cystocele, rectocele. 
or both, as well as to partial or even complete prolapse of the uterus. The 
well-known fact that these results do not always follow constitutes no 
justification for neglect. The tragic results of neglected tears of the third 
degree are common knowledge. In addition to the consequences above 

431 



432 PATHOLOGY OF PREGNANCY AND LABOR 

mentioned, the patient's life may be made a burden to her by loss of rectal 
control. 

Time for Operating. — When should the laceration be repaired? At 
once, if circumstances are favorable, i.e., if the patient's condition is good 
and if the operator is competent for the task. It is the custom of many 
men to insert the sutures while waiting for the delivery of the placenta, 
not tying them, of course, until the placenta has been delivered. This is 
convenient and permissible in slight tears involving only the skin and 
mucous membrane, but obviously improper in cases of severe laceration. 
Such cases require the entire attention of the operator, and should be post- 
poned until he is relieved of all anxiety about the condition of the patient, 
the delivery of the placenta, the possibility of hemorrhage, etc. 

Many an operation has been omitted or imperfectly performed because 
the circumstances were unfavorable, e.g., because the patient's general con- 
dition was not good, or the necessary assistance was not at hand, or the 
attendant distrusted his ability to perform a difficult perineorrhaphy, and 
perhaps supervise the administration of an anaesthetic when exhausted by 
anxiety or loss of sleep. In a case like this it is far better, after irrigation 
of the vulva and covering the parts with a sterile dressing carefully held in 
place, to wait from twelve to thirty-six hours. The patient will then have 
recovered from the shock of labor, and the operation can be carefully 
and deliberately performed, under ether anaesthesia, if necessary, by a good 
light, and with the necessary assistance. Moreover, as I have recently 
become convinced by experience, the operation performed at this time is 
much easier. The swelling has subsided, the relations of the parts can be 
better determined, and the operator's view is not obstructed by the constant 
flow of blood and liquor amnii. If this practice were generally followed, 
we would not so often meet with cases in which one or tw^o hastily placed 
sutures at the vaginal outlet conceal a serious laceration within. 

Technic— The repair of perineal tears is always a difficult matter for 
the beginner. Indeed, many never acquire correct ideas upon the subject 
at all. Circumstances render it difficult or impossible to photograph the 
various steps of the operation and the efforts to enlighten the beginner by 
means of diagrams have proven a colossal failure. Some of these diagrams 
are utterly incomprehensible, even to those who have given much thought 
to the subject, and certainly represent nothing that one sees in real hfe. 
Experience has taught me that it is better to master the general principles 
that underlie the subject, to avoid a multiplicity of diagrams, and for the 
rest to trust to a good light and a sufficient knowledge of anatomy. 

Few instruments are needed. Needles should be strong and have a 
large and sweeping curve, about that of a half-dollar. Small and fragile 
needles are useless and inefficient in making the circuit of the swollen 
tissues and are Hkely to be broken in the attempt. A good needle holder is 
a necessity. Very useful and much to be preferred, especially for sewing 
up tears in the sulci, is the Emmett needle with an eye in the point. Two 



LACERATIONS OF GENITAL TRACT 



433 



pairs of volsella will be found very convenient for seizing and defining the 
angles of the tear (Fig. 259). Silkworm gut is the preferable material for 
suture. It is cheap, easily disinfected — simple boiling suffices — and does not 
absorb the lochia! secretion and thus cause stitch abscesses. Fine catgut 
should be at hand, however, for buried sutures, should these be necessary, 
e.g., in uniting the ends of the rectal sphincter, or in sewing up the recto- 
vaginal septum. 

A good light and a good view of the field of operation are indispensable. 
The operator should spare neither time nor pains in securing these. Per- 
haps it is not too much to say that this is the most important of the whole 
procedure. Once he has determined exactly what he has to do, the battle is 




Fig. 259. — Showing Emmett needle and use of the volsella. 



more than half won. The placing of the sutures is a mechanical matter of 
no great difficulty, but there are a few simple rules which it is important 
to remember. 

For easy operations it may be sufficient to place the patient in the 
cross-bed position, but in the case of a complete tear, or one which extends 
up one of the vaginal sulci, a table should be used. There should be no 
hurry or excitement, and everything should be done with deliberation and 
care. The patient should be in the dorsal position with the hips drawn 
to the edge of the table, and the vulva and adjacent parts washed with 
lysol solution. A sterile towel or one wrung out of lysol solution is placed 
under the buttocks. 
28 



434 PATHOLOGY OF PREGXAXCY AXD LABOR 

The first thing required is a systematic inspection of the parts by a good 
hght. Wide separation of the labia together with free irrigation is usually 
sufficient. In the case of a primipara it should be remembered that an 
apparently normal condition of the external parts may coexist with an 
internal tear, and it is sometimes advantageous to evert the posterior 
vaginal wall through the rectum, paying special attention to the lateral 
fornices. If this is done, a glove should, of course, be worn and then 
discarded. Inspection to be thorough should be , systematic. The at- 
tendant should first satisfy himself that the sphincter ani and the recto- 
vaginal septum are intact. This is usually easy. The parts are directly 
accessible to sight and touch. In case of doubt the finger introduced with 
the precautions just mentioned will settle the question. 

The next step is the inspection of the perineal body. This may be 
accomplished with a little care by separating the labia and irrigating or 
sponging the parts, a tampon being inserted meanwhile in the upper part 
of the vagina to diminish the flow of blood and liquor amnii over the parts. 
Do not overlook a pocket that is often found behind an apparently intact 
posterior commissure. Do not forget to remove the tampon. 

The third step never to be omitted is the inspection of the posterior 
vaginal sulci. This is the most troublesome part of the whole procedure, 
but with care can always be accomplished. If the sulcus is not the seat of 
a tear its congested mucous membrane will present an unbroken surface 
when the flow of blood from above is temporarily checked or wiped away. 
If a tear is present the blood wells up from beloAV and is constant, even 
if the flow from above is stanched. AMth careful sponging the edges of 
the tear can be made out. In case of doubt, palpation of the parts by two 
fingers, one in the vagina and the other in the rectum, is of the highest 
value, enabling one to recognize immediately the break of continuity in the 
muscle. It is in these cases particularly that the advantages of the de- 
layed operation are apparent. There is little or no bleeding and accurate 
coaptation of the parts is an easy task. 

Asepsis should be rigid. ^Meddlesome antisepsis is to be avoided. 
Experience has shown that if care is exercised in this respect good results 
are usually obtained. An extra pair of gloves should be at hand since the 
operator may be obliged to introduce a finger into the rectum. Douches, 
either before or after the operation, are best omitted but the external parts 
should be thoroughly scrubbed with lysol solution, and the field of opera- 
tion frequently irrigated with the same solution. After the operation is 
completed a large moist dressing of sterile gauze wrung out of ;^ per cent, 
lysol solution is applied (Figs. 260 and 261). 

Sensitive patients may require an anaesthetic. Suturing the vagina and 
cervix are painless, but the patients often object strenuously to the puncture 
of the skin. Some patients, indeed, are less able to control themselves at 
this time than during the second stage of labor. Ether or nitrous oxide 
should be the anaesthetic employed. The Relative safety of chloroform 



LACERATIOXS OF GENITAL TRACT 



435 



disappears after delivery, the tendency to uterine relaxation and hemor- 
rhage is greater than with ether and. if chloroform has already been used, 
the likelihood of delayed chloroform poisoning is increased. A competent 
anesthetist should be secured, if possible, so that the operator can devote 
his entire attention to his work. 

Two mistakes are almost always made by beginners in this work. The 
needle is entered too close to the edge of the tear and the sutures are tied 
too tightly. After delivery the tissues about the vulva become much 
swollen. This swelling is especially marked in primipar?e, and after long 




Fig. 260. — Taking a suture in a tear of the first degree. 

labors and operative deliveries, in fact in those cases in which perineor- 
rhaphy is most often required. The two mistakes above mentioned cause 
the stitches to cut through. If the stitches are tied tightly the swelling of 
the tissues causes them to cut through, and if the needle is inserted close 
to the edges of the tear the constricted tissues may be completely severed. 
Hence the following rule: the needle puncture should be made at some 
distance one-half inch or more from the edge of the tear, and should be 
tied just tightly enough to bring the torn margins together but no more. 
Neglect of these rules is the cause of many failures. As a rule, the needle 



436 



PATHOLOGY OF PREGNANCY AND LABOR 



should be carried completely around the tear, i.e., it should not appear in 
the wound. If this is not possible, as is often the case in sewing up tears 
in the vaginal sulci, the point of the needle should be brought out in the 
deepest part of the wound, and reentered near the same point. In this 
way the formation of pockets is avoided. Whenever the suture is to 
include anything more than skin and mucous membrane care should be 
taken to secure a good bite of tissue on either side and thus to bring securely 
together the separated muscles. 




Fig. 261. — Same case. 



Sutures of silkworm gut. The ends are left long in order to prevent them 
from pricking the patient. 



A\'ith these facts in mind let us consider separately the treatment of 
the more common varieties of laceration. 

Excluding mere " nicks " or tears, involving only the skin and mucous 
membrane, which require only two or three superficial sutures and whose 
repair needs no special description, there remain for separate consideration 
three principal varieties. 

Tears of the first degree, involving more or less of the perineal body 



LACERATIONS OF GENITAL TRACT 



437 



proper, and causing more or less injury to the muscles that guard the outlet 
of the vagina. 

Tears of the second degree, running up one or the other vaginal sulcus 
and endangering the integrity of the levator ani muscle. 




^. ^: 



ii 



m 



Fig. 262. ^Introduction of sutures in a tear of the first degree. 

Tears of the third degree, involving the sphincter ani and perhaps the 
recto-vaginal septum. 

Tears of the First Degree 

Inspection of the parts shows two triangles, a small upper intravaginal 
triangle, involving usually only the mucous membrane, and a somewhat 
larger external triangle involving the skin surface and more or less of the 
perineal body. The vaginal sulci are not involved. The sphincter is 
untouched. It is an extension of the tear of the fourchette so very common 
in primiparae. 

It is best closed by two or three sutures from the skin side, as shown 



438 PATHOLOGY OF PREGXA^XY AXD LABOR 



,d^- 




e^%^ 



o ^ c^ 




LACERATIONS OF GENITAL TRACT 



439 



in Figs. 262, 26^, and 264. These sutures should be buried, not appearing 
in the wound. It will be noticed that suture 3 is so placed as to bring the 
opposing angles accurately together, thus restoring the parts to their former 
position. Superficial sutures may be placed as needed. After the closure 




Fig. 265. — Repair of unilateral second degree tear of pelvic floor. (Polak's Manual of Obstetrics, 

D. Appleton & Co.) 

of the perineal tear two or three superficial sutures suffice to unite the tear 
in the vaginal mucous membrane. 

Tears of the Second Degree 

Suppose that the perineal tear is not ah, that careful inspection, never 

to be omitted, discloses a tear running up one or the other vaginal sulcus. 

Modern gynaecology shows that such tears, dividing as they do the levator 

ani, have much more to do with subsequent pelvic disability than do tears 



440 



PATHOLOGY OF PREGNANCY AND LABOR 



that extensively divide the perineal body. If we could repair but one it 
would be better to repair the tear in the sulcus and leave the tear in the 
perineum unrepaired. And yet, how often is the perineum repaired and 
the more serious injur}^ untouched. 

These tears must, of course, be sutured from above downward. The 
first suture is placed near the angle of the wound. If, perchance, the 
operator does not get his first suture high enough it can be used as a 
traction handle by which to draw down the tissues and place a second 
suture where he tried to place the first. Large and strong needles are 
necessary and the needle should be svrept well outward so as to secure a 



k 




Fig. 266. — Tear involving the sphincter ani. Sutures in place. 2 denotes the buried suture. 

good " bite " of the levator ani, whose union is so important to the future 
welfare of the patient. In these tears there is usually so much tissue to be 
encircled that it is necessary to bring the needle out in the centre of the 
wound and reenter it. In doing this the point of the needle should be 
carried somewhat downward, so that the point of exit is a little lower than 
the point of entrance and, when reentered, should be carried upward until 
it is brought out opposite where it was first entered, as suggested by 
Howard Kelly. Thus when the sutures are tied the muscular walls of the 
vagina are lifted upward into their original position. It is impossible to 
photograph this process, and not easy to describe it, but it is sufficiently 
illustrated by the accompanying diagrams (Figs. 265 and 266). 



LACERATIONS OF GENITAL TRACT 441 

Rarely both sulci are tern and it is necessary to repeat the process on 
the other side. In these cases a tongue of posterior vaginal wall may be 
separated from its attachments, its lower end hanging loosely in the vagina. 
In repairing the sulci some of the stitches will of necessity pass through 
this flap and care should be taken that it remain in its original position. It 
is safer to leave a small space at its lower end for drainage. 

After the closure of a tear in the vaginal sulcus there remains only a 
tear of the first degree, which should be repaired as already described. 

Tears of the Third Degree 

These tears should never be neglected. Repair may and should be 
postponed until the next day if the immediate circumstances are unfavor- 
able, but failure to repair is inexcusable neglect. Some writers state that 
the operation is very difficult and requires all the paraphernalia of the 
gynaecologist. This is a disastrous mistake and has undoubtedly deterred 
many a man from attempting repair when he might easily have succeeded. 
In my experience the operation is less difficult than that for the repair of 
bad vaginal tears. The whole operative field lies directly under the eye, 
the denudation has already been done by nature, there is no hemorrhage 
from any part of the operative field, no more instruments are needed than 
for an ordinary perineorrhaphy, and with proper technic success is the 
rule. Experience has taught me that the only really necessary instruments 
are a needle and needle holder, a scissors, and a thumb forceps or some 
similar device for " fishing out " the retracted ends of the sphincter. In 
an emergency one might even dispense with the needle holder. Doubt- 
less the exaggerated idea of the difficulty of the operation arose from the 
difficulties encountered in the secondary operation performed some months 
later, an entirely different matter. 

Let the attendant remember that if he only succeeds in bringing the 
ends of the sphincter ani together and keeping them together he has done 
his patient an inestimable service. 

When the sphincter ani is involved the tear often, though not always, 
extends to the recto-vaginal septum. If this is the case the tear in the 
septum is first closed from above downward by interrupted sutures of fine 
gut, upon a small needle. The usual perineorrhaphy needle is too large 
for this purpose. Hence a small needle and a roll of fine gut should 
always form part of the equipment of the accoucheur. The sutures 
should not enter the rectum but should be tied upon the vaginal side. 
These, as well as the sutures in the sphincter, will be buried when 
the operation is complete. To knot the sutures in the rectum and let 
the ends hang out of the anus, as is often described and illustrated, is 
to invite sepsis. 

The septum being closed the next step and the most important step of 
the whole operation is the closure of the sphincter. First the fragment of 
the sphincter is seized and drawn out of the pit into which it has usually 



442 



PATHOLOGY OF PREGNANCY AND LABOR 



retracted and transfixed by the needle threaded with catgut. The same 
process is repeated upon the other side, the separated ends are then 
brought together and the suture is tied. One or more sutures are 
introduced to reinforce the first. The recto-vaginal septum and sphincter 
having been repaired the remainder of the tear should be closed by the 

Fig. 267. Fig. 268. 



a 





Figs. 267-268. — Repair of the recto-vaginal septum. Fig. 267, correct method; Fig. 268, incorrect 

method. 

methods already described. Care should be taken that the buried sutures 
in the sphincter are completely covered (Figs. 267 and 268). 

Tears of the anterior vaginal wall or of the anterior sulci are not 
common, but should always be thought of and sought for since they may 
sever the urogenital trigonum and thus become the cause of cystocele. 
These injuries are usually on the left side, probably because of the fre- 



LACERATIONS OF GENITAL TRACT 



443 




quency of the L. O. A. position. Among the causes noted are disproportion 
between the head and soft parts and imskilful efforts at rotation of the 
posterior occiptit with the forceps. The diagnosis is confirmed by palpat- 
ing the muscle along the pubic bone. The tear should be closed by 
interrupted sutures, which should be made to secure a firm and sufficient 
hold of the separated ends of the muscle. 

Now and then a large flap of mucous membrane, or even an entire 
labium minus, may be separated from the underlying tissue, remaining 
attached along one margin only. In these 
cases the edges should be re-attached by 
interrupted sutures of catgut, a space 
being left at the lower border for drainage. 

Atypical and irregular lacerations 
must be treated upon general principles, 
but there are certain varieties that require 
brief mention. Tears in the neighbor- 
hood of the clitoris and anterior commis- 
sure are rare, but when they do occur may 
be the source of alarming hemorrhage. 
Fatal cases have been recorded. This 
free bleeding is due, as Garrigues has 
noted, to the fact that the pelvic veins 
all communicate with each other and are 
without valves. Prompt and secure 
hasmostasis is secured by the ligature, and 
by this alone (Fig. 269). 

Management of Bowels. — Before 
taking up the after-treatment of perineal 
lacerations in general we should refer to 
one important point in connection with 

the repair of those of the third degree — I refer to the subsequent 
management of the bow^els. Many writers, including some eminent 
gy^nsecologists, advise that salines be administered on the second day 
and every day thereafter. However this may be in the case of sec- 
ondary perineorrhaphy, I believe it to be a mistake in obstetric practice, 
increasing the danger of infection, requiring unnecessary handling of the 
parts at a critical time, and subjecting the freshly sutured sphincter to an 
unnecessary and highly undesirable strain. 

My own practice, following the method of Bumm, has been to give 
food that leaves little fecal residue, e.g., clear soups, broths, or liquid pep- 
tonoids, and on the fourth or fifth day a dose of castor oil. I have in some 
instances waited until the fifth day. Milk and solids should be avoided at 
this time, as tending to result in the production of hardened fecal masses. 
An occasional cracker or stalk of celery does no harm. 



Fig. 269. 



-Tears in the region of the 
vestibule. 



444 PATHOLOGY OF PREGNANCY AND LABOR 

I have been called upon to perform this operation in hospitals, private 
houses and tenement houses, in a word, under all kinds of circumstances 
and conditions, and following the above simple rules my results have been 
unifomily good. I do not mean, of course, that the result in every case 
has been perfect ; but, with perhaps one or two exceptions, there has been, 
at least, union of the sphincter and recto-vaginal septum, with control over 
the bowel movements. L^nless the recto-vaginal sphincter has been care- 
fully repaired, and sometimes in spite of this, a recto-vaginal fistula will 
remain and may persist for some weeks. Li my experience, however, no 
special treatment has been necessary, rest in bed and simple cleanliness, 
together with the exercise of considerable patience, having been sufficient 
to effect a cure. 

After-treatment of Perineal Lacerations in General. — The patient 
should be let alone as much as possible. Vaginal douches are unneces- 
sary and probably detrimental. The parts should be kept clean by 
irrigation but all handling should be forbidden. The use of the catheter 
should, if possible, be avoided. Inspection of the parts for the purpose of 
determining whether union is taking place is not to be recommended. The 
sutures are removed in from eight to ten days. If infection occurs they 
are, of course, removed earlier. As a rule, however, with reasonable care 
good results are obtained. 

H.EMATOMA 

But all lacerations are not visible. Sometimes the mucous membrane 
remains intact though the vascular structures beneath are torn. In this 
case the concealed effusion of blood shows itself in the form of a tumor, 
which is called a hsematoma (blood tumor). This tumor appears suddenly 
and takes the form of a diffuse swelling, bluish and congested in appearance 
and very sensitive to the touch. It is unilateral, involving one side of the 
vulva, and the adjacent structures. It is said to occur about once in 
seventeen or eighteen hundred cases, but in my experience the form which 
we are at present considering occurs somewhat oftener. It appears to be 
more common after rapid deliveries and especially after rapid forceps 
deliveries. Sometimes, however, it appears earlier and may even consti- 
tute an obstacle to delivery. 

There is a form in which the eff'usion is above the pelvic fascia. It is 
very rare, indeed, most men never having seen a case. Perhaps it has been 
an occasional unrecognized, and therefore unreported, cause of death after 
delivery. The initial swelling is in the upper part of the vagina, but there 
appears to be hardly any limit to its possible extension. The effused blood 
may dissect its way beneath the peritoneum as high as the diaphragm, or 
it may rupture into the peritoneal cavity. The symptoms are those of 
acute anaemia and of shock, added to the presence of the swelling in the 
upper part of the vagina. 

Treatment. — The ordinary variety of h3ematoma,the vulvar hsematoma, 



LACERATIONS OF GENITAL TRACT 445 

is best treated expectantly. Scrupulous external cleanliness is all that is 
necessary. Handling the parts should be avoided as predisposing to 
infection. The parts are kept covered with a large pad of sterile cotton, 
since bruising or abrasion may result in infection. The temptation to 
interfere should be restrained. 

Under this simple treatment the great majority of cases go on to 
recover}' without complications. Should symptoms of infection appear, 
however, or should the tumor burst and continuous bleeding follow, the 
tumor should be incised and packed with gauze. 

Few have had sufficient experience with the subperitoneal form to be 
able to draw conclusions with reference to treatment. The conditions are 
somewhat analogous to those in rupture of the tube in ectopic gestation, 
and if active hemorrhage is going on the only resource would seem to be 
to open the abdomen, remove the clots and stop the hemorrhage by 
compression or ligature. 

Tears of the Vagina 

Tears of the vagina are, as a rule, simply downward continuations of 
cervical tears or upward continuations of perineal tears. They are for 
the most part longitudinal. Perforating tears of the vagina are hardly 
possible except as the result of inexcusably careless or clumsy work with 
the forceps. Tears of the upper part of the vagina, however, do sometimes 
occur quite independently of those of the cervix or perineum and may com- 
municate with the peritoneal cavity. These tears are closely analogous to 
ruptures of the uterus and like these are usually transverse. They are the 
result of great distention, as in the case of a large head and a small canal. 
Sometimes they extend entirely around the upper end of the vagina, 
separating it completely from the cervix. The older writers called this 
colporrhexis. The vagina, like the uterus, may undergo pressure necrosis 
in spots. This is one of the occasional results of delayed labor, especially 
in cases of contracted pelvis. Vesico-vaginal fistula, formerly so common, 
is an example of this. 

Treatment. — Extensive lacerations of the upper part of the vagina, 
and of the cid de sac, communicating perhaps with the peritoneal cavity, 
should be treated upon the same general principles as rupture of the titerus. 
Less extensive tears usually heal spontaneously if conditions are favorable, 
i.e., if infection does not occur. Suturing in this region is difficult and 
probably does more harm than good. If the tear communicates with the 
rectum the resulting fistula should be treated as above described. 

Tears of the Cervix 

A moderate bilateral tear is, as we have seen, the usual result of labor at 
term. Its traces are found in almost every woman who has borne a child 
and need excite neither surprise nor anxiety. More extensive tears, and 
in particular those which give rise to hemorrhage, should be sutured. The 



446 



PATHOLOGY OF PREGNANCY AND LABOR 



proposal has recently been made that after every delivery the cervix should 
be inspected. This is quite unnecessary and would undoubtedly increase 
the danger of infection. In hospital practice, however, and in private 
practice whenever conditions are favorable, the cervix should be inspected 
and if necessary repaired after high and median operations, versions, 
manual or instrumental dilatation of the cervix, or the induction of 
abortion or of premature labor. 




Fig. 270. — Immediate repair of the cervix. It is seldom necessary to use as many stitches as indicated 

above. 

The chief immediate significance of tears of the cervix from a clinical 
stand-point is their relation to postpartum hemorrhage, and they are fully 
discussed in connection with that subject (Fig. 270). 

Rupture of the Uterus (Figs. 271, 272, and 273) 

Frequency. — This is a rare accident. Averaging the reports of a large 
number of observers it is found to occur once in about thirty-five hundred 
■cases. Probably it occurs more frequently in private than in hospital 



LACERATIOXS OF GENITAL TRACT 



447 



practice, since in the latter there are better faciHties for watching the 
progress of labor and for timely operative interference. It is also probable 
that trainiiatic rupture, the result of forced deliver}^ occurs, both in and out 
of the hospital,, more frequently than is usually supposed. 

Varieties.— As regards the method of production there are two 
varieties, spontaneous and traumatic. As regards its extent there are again 
two varieties, complete and incomplete. Spontaneous rupture is the result 
of the forces of nature alone, as in obstructed labor. Traumatic rupture is 
the result of violence from without, e.g., an ill-timed or unskilfully 
conducted version. 

Character of Injury. — Rupture of the uterus occurring during preg- 
nancv tisuallv involves the body of the uterus since it is, as a rule, the result 
of a defect in the uterine wall, perhaps the scar of an old operation, or 
destruction of tissue due to the presence of a tumor. Ruptures occurring 

Fig. 271. 




Fig. 272. 




Fig. 271. — Character of the lower uterine segment in a primipara at the eighth month. Progressive 

thinning of the pericervical region. The finger perceives this at a height of one centimetre. 
Fig. 272. — Character of the lower uterine segment in a primipara at term. Pericervical region thin 

at a height of five centimetres. 

during labor, however, are usually the result of pressure and overdistention 
and, as might be expected, involve for the most part the lower uterine 
segment, the thinned and distended portion of the uterus which, as we 
have seen, plays during the greater part of pregnancy such an insignificant 
part but becomes so prominent during labor. Of the ruptures that occur 
during labor those that are spontaneous, in other words those that occur 
without external violence, may be irregular in shape but are usually the 
result of the extension of a cervical tear, are longitudinal, and often extend 
into one of the broad ligaments, often with a resulting hjematoma. In rare 
instances the tear is circular, the vaginal portion of the cervix being 
separated from its attachments, literally torn off. 

Pressure necrosis of the uterine wall or some portion of the genital 
tract was formerly common. It was the result of long-continued reciprocal 



448 



PATHOLOGY OF PREGXAXCY AXD LABOR 



pressure between the fetal head and some part of the pelvis, e.g., the 
symphysis pubis. In the latter case the result was a vesico-vaginal fistula, 
seldom seen under modern methods of treatment. Sometimes the point of 
contact was with the sacral promontor}-. This, as may well be imagined, 
was often the case in pelvic contraction. The perforation was in the 
posterior uterine wall. Again the point of contact was some exostosis and 




J'lG. 273. — Rupture of the anterior wall of the cervix uteri. (Wood's Museum, Bellevue Hospital, 
No. II39-) One-third actual size, a, contraction ring; b, rupture; c c, external os. 



the perforation might be opposite any point upon the inner surface of the 
pelvic wall (Fig. 274). 

Time cf Occurrence. — Rupture of the uterus may occur during preg- 
nancy, but this is very rare, and most observers, even among those of large 
experience, know of it only by hearsay. Most cases occur after labor has 
been in progress for some time or, at all events, in the course of some 
operation designed to hasten deliver)\ 

Etiology. — Two principal causes predominate. Delayed or obstructed 
labor, and unskilful attempts at delivery. Formerly, when women were 



LACERATIONS OF GENITAL TRACT 



449 



allowed to linger for hours in labor, when the Csesarean section was 
attended by a mortality of 50 per cent, or more, and when the forceps 
operation was considered only as a last resort, rnpture of the uterus was 
naturally more common than now. I fear, however, that traumatic rupture 
has not decreased very much in frequency. Rapid dilatation of the cervix 
followed by rapid delivery, as advised by some writers and in some text- 
books, is sometimes responsible. Rapid extraction in placenta prsevla is 
often responsible. Attempts at forceps delivery or version, practised 




ernal os 



! Anterior 
vaginal 
wall 



Neck of 

the 

bladder 



Fig. 



! 74. —Pressure against cervix posteriorly, anterior vaginal wall and neck of bladder, in case of 

contracted pelvis- 



before complete dilatation of the cervix, are fruitful sources of trouble in 
this respect. Indeed, I believe that every obstetrician of experience sees 
an occasional death attributed to shock or hemorrhage which is really due 
to a tear involving the lower uterine segment. More than one such case 
confirmed by autopsy has fallen under my observation. All these matters 
are discussed elsewhere, but they are so important that they will bear 
repetition. 

In olden times the improper use of ergot was without doubt an occa- 
sional cause of uterine rupture, but now this must be rare indeed. To 
29 



450 PATHOLOGY OF PREGNANCY AND LABOR 

make up for this, however, we now have a new etiological factor, the ill- 
timed employment of pituitrin. 

Among the predisposing causes is multiparity. Naturally, the lax and 
atrophied uterine wall of a woman who has borne many children does not 
stand the strain of labor as well as it once did. Then, too, in these days 
of repeated Cesarean section, such a uterus not very infrequently contains 
a weak spot in the shape of a long cicatrix. Again such a cicatrix may be 
the result of efforts to remove an adherent placenta. Tumors may pre- 
dispose to uterine rupture in two ways, by replacing part of the uterine wall 
and thus making a "weak spot," or directly blocking the exit of the foetus 
and thus indefinitely protracting labor. Pendulous abdomen and other 
conditions involving faulty uterine axis prolong labor and thus constitute 
a predisposing cause of rupture. The same thing is true, of course, of 
abnormalities of the bony canal and especially of pelvic contraction. 

In the rare cases in which rupture occurs during early pregnancy the 
cause is variable. If we except, as we should, cases of tubal pregnancy, 
rupture occurring during the early months is usually the result of some 
malformation, as in pregnancy in the rudimentary horn of a bicornate 
uterus, or it may be traumatic, as in the case of the traditional and much 
quoted instance of the goring of a pregnant woman. During the later 
months increasing distention and the painless contraction of pregnancy, 
which are sometimes quite powerful, may, in the presence of some pre- 
disposing cause, produce rupture. In some cases careful examination has 
failed to reveal the cause. 

Mechanism. — If we recall our studies in the physiology and mechan- 
ism of normal labor the mechanism involved in uterine rupture at once 
becomes plain. The reader will recall that the lower uterine segment is the 
thin, distensible, non-contractile part of the uterus. When for any reason 
the contractions of the body of the uterus are not able to cause the descent 
of the foetus it is easy to see that their only effect can be to increase to an 
abnormal extent the distention and thinning of the lower segment. This 
is shown clinically by the fact that the contraction ring, which is nothing 
more than the raised lower boundary of the body of the uterus, is found 
at a high level, perhaps as high as the umbilicus, whereas in normal labor 
it is hardly perceptible and reaches only about to the level of the pelvic 
brim. In addition to the distention of the lower segment there may, of 
course, be present some one of the predisposing causes already mentioned. 
The above, however, is the usual mechanism in spontaneous rupture. It is 
perfectly obvious that the -tendency to rupture is increased when the foetus 
is gradually crowded into a transverse position in the lower uterine 
segment. 

Clinical History. — Rupture of the uterus is usually preventable. 
Though rare, one is as likely to encounter it as another. Indeed, it is 
especially likely to occur in neglected cases in sparsely settled communities, 
where medical assistance is not available, or perhaps in the practice of 



LACERATIONS OF GENITAL TRACT 451 

midwives. Here the physician often finds himself obHged to combat 
threatening symptoms which have been alloAved to develop through no 
fault of his own. 

\Miat are these symptoms? The general symptoms are those of 
delayed labor already described. The local symptoms are highly 
characteristic. 

Since it is the lower uterine segment that is subjected to the greatest 
tension the most acute symptoms are referred to the lower abdomen. 
There is great tenderness in this region. The lightest touch is resented 
and satisf actors^ palpation without an anaesthetic is quite impossible. Owing 
to the thinning of the lower uterine segment and its close application to the 
fetal body the fetal heart-sounds are heard with startling distinctness. 
The contraction ring, now very thick and bulky, can be felt, and even plainly 
seen, as high as the umbilicus and even higher. To the eye the picture 
resembles that of bladder distention. Above the contraction ring the body 
of the uterus is found very much thickened and in this region palpation, 
even with an anaesthetic, is unsatisfactory. The fundus is high and carried 
far to one side and the round ligaments, stretched to their utmost extent, 
can be plainly felt and their outlines seen through the abdominal wall. 
Perhaps some one of the well-known conditions which favor rupture may 
be recognized — a transverse position of the foetus, a hydrocephalic head, a 
•contracted brim, or some other cause of* delayed labor. The history of 
labor is one of long and fruitless effort. 

Spontaneous rupture usually occurs suddenly and at the height of a 
contraction. There is a sharp and sudden pain, different in character from 
those which have gone before. The patient cries out perhaps that some- 
thing has burst. After this the contractions cease and the pain becomes 
less severe. The pallor and the weak '' running " pulse so characteristic 
of this accident are not long in making their appearance. Vomiting, a 
peritoneal reflex, and hemorrhage from the cavity of the uterus are 
prominent symptoms. 

With all this, in a typical case, go the classical and unmistakable 
symptoms of rupture. The presenting part, usually the head, recedes or 
even seems for the moment to have disappeared. Coils of intestine may 
protrude and the hand introduced into the uterus may palpate the rent 
directly. If, as sometimes happens, the child has passed completely 
through the rent into the abdominal cavity, the uterus and the child may be 
recognized as two separate tumors. Perhaps the operator has been in the 
midst of a difficult version and the sudden lack of resistance may lead 
him to congratulate himself upon his success. But he is soon undeceived. 

However, not all cases are typical. Nor do the symptoms appear so 
suddenly. Very rarely the head may have descended so far and have 
become so imprisoned within the pelvis that it cannot recede. Very rarely 
threatening symptoms may be in abeyance for a time. Hirst records a 
case in which there were no alarming symptoms until twenty-four hours 



452 PATHOLOGY OF PREGNANCY AND LABOR 

after the escape of the child into the abdominal cavity, and another in 
which abdominal section, a month after deliver)^ for supposed intra- 
peritoneal abscess, showed an extensive rent at the fundus, which was 
being shut off from the general peritoneal cavity by an exudate which was 
undergoing suppuration. 

Traumatic rupture, of course, is not necessarily preceded by these 
symptoms though it may follow an attempt at their relief. In most cases 
of traumatic rupture the symptoms are those of the condition for which the 
operation is undertaken — perhaps eclampsia or placenta praevia. The 
symptoms of rupture do not appear until after some operation and are 
then often unrecognized. They are essentially those of hemorrhage and 
shock, but the hemorrhage does not come from the cavity of the uterus. 
There is probably more or less laceration of the cervix but the symptoms 
are more threatening than would be expected from the visible loss of blood 
and the shock more severe than circumstances seem to warrant. In these 
•cases there is usually a laceration of the cervix, which proves to be greater 
than was at first supposed. Sometimes the operator even imagines that it 
has been satisfactorily repaired. 

Diagnosis. — About the only obstetric accident which is likely to be 
mistaken for rupture of the uterus is accidental hemorrhage. Here the 
evidences of acute anaemia and of shock coming on suddenly during preg- 
nancy or labor remind one strongly of rupture of the uterus. There is, 
however, no recession of the presenting part and, in the concealed form, 
which is really the worst form, there is, of course, no visible hemorrhage. 
Moreover, rupture of the uterus usually occurs late in labor and is 
preceded by the classical symptoms of delayed labor. 

Difficulty may arise in determining the character and extent of the 
rupture and particularly whether it is complete or incomplete. Garrigues 
lias noted that the abdominal viscera can be felt so plainly through the 
thin and delicate peritoneum that it may be impossible to tell whether 
this membrane is still intact or not. In case of doubt it might be well to 
adopt the suggestion of Polak and make a digital exploration through an 
incision in the posterior ctd de sac. 

Prognosis. — This is always serious. In former times, before the de- 
velopment of modern antiseptic methods, 90 per cent, of the mothers were 
lost and even now, under the best methods, maternal mortality is probably 
not less than 50 per cent. Most of the children are lost, some from the 
delayed labor and futile attempts at delivery, others by the death or very 
serious general condition of the mother, and still others by the fact that the 
rupture may involve the placental site and thus interfere directly with the 
exchange between mother and foetus. In some cases the placenta is 
completely detached. 

Prophylactic Treatment. — This is of paramount importance. It is far 
easier to prevent rupture of the uterus than to remedy its consequences. 
With the exception of those very rare cases in which the uterine wall has 



LACERATIONS OF GENITAL TRACT 453 

been weakened by tumor formation or operative cicatrices, rupture of the 
uterus should not occur; i.e., of course, in cases which have been under 
medical supervision from the beginning of labor. The attendant should 
never forget to look for the premonitory signs in every case of delayed 
labor. It is a tragic mistake to wait until these signs are forced upon one's 
attention. It will not do to assume that, because a condition is rare, it will 
not be met with in general practice. Indeed, such an accident as this is 
more likely to occur in neglected cases in far off localities than in hospitals. 

Cases of delayed labor should not be neglected. Malpositions, espe- 
cially shoulder presentations, should be corrected before it is too late. In 
these days of repeated Csesarean sections a patient with a uterine cicatrix 
should not be allowed to linger too long in labor. In the rare cases in 
which a patient who has already survived one rupture of the uterus becomes 
pregnant again, the Csesarean section should be performed early in labor. 

Such anomalies as hydrocephalus and face presentation should be rec- 
ognized early in labor. Here the importance of a good knowledge of 
external palpation is manifest. A thorough training in the external 
diagnosis of pregnancy and labor would have saved many a uterus from 
rupture. 

The technic of the various operations for delivery is described elsewhere 
and it is quite unnecessary to tell any intelligent student or practitioner 
that, in the presence of symptoms threatening uterine rupture, delivery 
should be accompHshed as soon as practicable, or that he should study 
carefully the subject of delayed labor and the technic of obstetric operations 
intended to bring about delivery. 

It is worth our while to mention one or two points which are usually 
neglected. 

Delivery by the forceps through a partly dilated cervix should not be 
undertaken. If such delivery is indicated the cervix should first be dilated 
by other means. Except in cases of placenta prsevia or dead foetus the 
same rule holds in the operation of version. It is by violations of this 
rule that the worst cervical tears are produced, tears that may extend far 
up into the lower uterine segment and are beyond the possibility of repair 
through the vagina. My own experience leads me to believe that careful 
substitution of the axis-traction forceps for the older instrument in all 
high and most median operations will do much to diminish the frequency 
of cervical tears and indirectly of tears of the lower uterine segment. 

The so-called accouchement force, i.e., the rapid and forcible dilatation 
of the cervix before the disappearance of its canal, followed by a forced 
delivery, should be tabooed as far more dangerous than any complication 
which it is intended to cure. 

If craniotomy is performed in the presence of a much distended lower 
uterine segment, traction upon the head in order to fix it at the brim should 
as far as possible be dispensed with. This is a useful observation of Carl 
Braun. 



454 PATHOLOGY OF PREGXA^XY AND LABOR 

The oxytocics, ergot and pituitrln, both valuable when indicated, are to 
be used with discretion. Speaking generally we may formulate the two 
following rules : 

Ergot should not be given until the placenta has been delivered. 

Pituitrin should not be given unless the cervix is completely, or almost 
completely, dilated, and there is no serious mechanical obstacle to delivery. 

These rules are not absolute, as we have already seen. There are 
occasional exceptions to the first rule and to the first part of the second. 

Curative Treatment. — If the foetus has escaped into the abdominal 
cavity, or if it has so far escaped that its withdrawal would be difficult or 
would probably increase the extent of the laceration, it should be promptly 
removed through an abdominal incision, and the same procedure should 
be followed if the head is above the brim or the pelvis contracted or the 
cervix hard and undilatable. Much manipulation in these cases is highly 
dangerous and there is no doubt that manual dilatation or any except an 
easy operative delivery would in the presence of uterine rupture involve a 
greater risk than the removal of the child by laparotomy. 

In cases like the above the course to be pursued is plain. The at- 
tendant has a serious duty to perform, but at all events he is relieved from 
the anxious responsibility of choosing between two radically different 
courses in a critical emergency. 

But suppose that the child is easily extracted, the bleeding only moder- 
ate, and the patient in fairly good condition. What is to be done? Two 
courses are advocated and practised. One is to tampon the uterus and 
vagina with gauze, apply an ice-bag externally, give morphine or pantopon 
hypodermically, and keep the patient perfectly quiet : the same treatment, 
practically, with the exception of the tampon, that would be employed in 
accidental perforation of the uterus during curettage. And, indeed, even 
in uterine rupture, it is better to omit the tampon if the bleeding is slight 
.or absent and when it is used to be careful, by inserting the first meshes of 
igauze rather loosely, that the rent is not increased or the bleeding started 
afresh. 

Other authorities advise laparotomy in all cases, citing the undoubted 
facts that hemorrhage that has ceased may recommence and that a large 
subperitoneal hsematoma may gradually form in cases that are apparently 
pursuing a favorable course. 

Statistics are obviously unreliable, and few men have had sufficient 
personal experience for a well-grounded personal opinion. Those who 
have had the most experience, e.g., Scipiades of Budapest, who has a 
record of nearly one hundred cases, and various other observers in the 
continental clinics where, owing probably to two factors, the greatest 
frequency of pelvic contraction and the very common employment of mid- 
wives, the accident has been far more common than in America, are in favor 
of the first method. Doubtless, as the technic and results of the more 
radical operation continue to improve it will be more frequently used but it 



LACERATIONS OF GENITAL TRACT 455 

is not likely to supersede the other in general practice. If the operator is 
in doubt the facilities for good surgical work and the experience of the 
operator will be the deciding factors. 

If the uterus is not to be removed, the edges of the peritoneal tear are 
to be carefully brought together in the manner already described in con- 
nection with the C^esarean section, and the wound drained through the 
vagina. If infection is deemed probable, or if the nature and extent of the 
wound demand, the uterus is removed. The supravaginal method is to be 
preferred as much easier and involving less risk, but in some cases the 
extent of the wound downward may necessitate total hysterectomy. The 
removal of the uterus postpartum is easier than its removal under ordinary 
circumstances, but the fact that, in this case, it must be performed upon 
a patient already profoundly shocked or perhaps almost in extremis does 
not add to the composure of the operator. 

Laparotomy for ruptured uterus is, of course, a hazardous undertaking, 
but in the cases in which it is clearly indicated it offers the only chance 
for the patient. This fact should be explained to her family. 

Ether or nitrous oxide should be the anaesthetic and saline infusion or 
other restorative measures should be practised while the patient is still 
upon the table. Jeannin advises that the abdominal surface be simply 
painted with iodine, all washing and brushing being sedulously avoided. 
Such procedures may result not only in increasing the bleeding but in 
massaging the uterine contents through the uterine rent into the 
peritoneal cavity. 

Unnecessary moA^ement in these cases is highly dangerous. Transpor- 
tation from the patient's residence to a hospital has proven fatal and even 
the transfer of the patient from the bed to the operating table should be 
conducted with the greatest possible care. 

Inversion of the L^terus 

This accident, somewhat akin to rupture of the uterus, is perhaps best 
considered here. The term explains itself. The uterus is turned either 
partly or wholly wrong side out — partial or complete inversion. Of course 
this cannot happen without some rupture or tearing of the uterine 
attachments, though the uterus itself remains intact (Fig. 275). 

Inversion of the uterus is one of the rarest of obstetrical accidents ; so 
rare indeed that it is difficult to estimate its frequency. Whitridge 
Williams tells us that not a single case occurred in two hundred and fifty 
thousand labors in the St. Petersburg Lying-in Hospital, and but one in 
two hundred thousand cases in the great maternity hospital of Dublin. 
Under these circumstances, it is not strange that few, even among those 
especially interested in obstetrics, have had the opportunity of studying 
the condition clinically. 

Inversion may be spontaneous or traimiatic. That is. it may be 
produced by intrinsic causes or by interference from without. An example 



456 



PATHOLOGY OF PREGNANCY AND LABOR 



of the first class would be uterine relaxation, one of the second pulling on 
the cord. 

Artificial causes are by far the more frequent. 

Inversion of the uterus is much less common than formerly. This is 
due to the fact that the management of the third stage of labor is better 
understood. It was formerly the custom to endeavor to dislodge the 
placenta while it is still in utero by pulling upon the cord. When this 
was combined with pressure upon the fundus, in the case of a relaxed 
uterus and a placenta attached at the fundus, the conditions for pro- 
ducing inversion would seem to be almost ideal. And yet, even when all 
this was the custom, inversion was a rarity. In a case which I saw with 
Dr. Charles P. Duffy the immediate cause seemed to be straining during 





Fig. 275. — Inversion of uterus. A, beginning; B, partial; C, complete. 



defecation, the patient being in the sitting posture. Of course, a well con- 
tracted uterus cannot become inverted. As Bumm says, such a uterus 
cannot be inverted artificially ; not even by the use of force. Relaxation 
of the uterus, or, at all events, relaxation of the fundus, is a necessary 
condition. Sometimes contraction of the lower uterine segment appears 
to grasp and draw down an indented and flabby portion of the fundus. 
Symptoms and Diagnosis. — The symptoms are sudden, acute, and 
highly threatening. Severe, sudden and tearing pain is followed immedi- 
ately by hemorrhage and profound shock. The attendant thinks perhaps 
of rupture of the uterus, but examination shows him his error at once. 
The hand laid upon the uterus shows that the uterus is wholly or in large 
part absent from the abdominal cavity. Internal examination recognizes a 
tumor in the vagina or sometimes just within the cervix — the inverted 



LACERATIONS OF GENITAL TRACT 



457 



fundus. In cases of complete inversion the fundus is seen protruding from 
the vagina, a bloody tumor covered with mucous membrane and often 
with the placenta attached. 

It would seem that there should be no difficulty in making a diagnosis 
of inversion, but among the curiosities of obstetrical literature is to be 
found the report of a case in which the inverted uterus was mistaken for 
the head of a second twin and the forceps were applied. In another it 
was mistaken for a polypus and ligated. We smile at such errors, but they 
may happen to any man who neglects careful bimanual examination. Just 
as in making the diagnosis of breech presentation it is not the presence 
of the breech at the pelvic brim, but the absence of the head that gives us 




Fig. 276. — Urethra dilated for introduction of finger into the bladder. 

our clue, so here it is not so much the presence of a foreign body in the 
cervix as the absence of the body of the uterus from its normal position 
that makes the diagnosis positive. 

Prognosis. — The prognosis is always very grave. It is usually esti- 
mated as about 30 per cent. The chief dangers are hemorrhage and shocks 
the latter being often attributed to the sudden diminution of the intra- 
abdominal pressure. To my mind a better explanation is to be found in 
considering the peritoneal investment and attachments of the uterus. In 
the case referred to above the patient was but four months pregnant and 
the size of her uterus would hardly be sufficient to make much dift'erence 
in the intra-abdominal pressure. Indeed the obstetrician, who so often sees 
the rapid subsidence of enormous abdominal distention, e.g., in hydramnion 



458 PATHOLOGY OF PREGNANCY AND LABOR 

and twin pregnancy, and, above all, in the Csesarean section, is apt to 
become sceptical as to the importance of this factor, upon which it is cus- 
tomary to lay so much stress. 

Treatment. — No one man has had sufficient experience to justify him 
in speaking with authority. Of course, the patient is often found in a state 
of profound shock and one hesitates to operate immediately. Doubtless it 
is better in some cases to wait. In the case of which I have spoken above I 
was forced to desist, after having partially reduced the inversion, my 
anaesthetist fearing to continue the anaesthesia. The patient rallied, how- 
ever, and the reduction was completed a few days later. In another case 
I was called by Dr. George Stevenson on account of profound collapse. 
This patient was a primipara, sixteen years of age, weighing 165 pounds ; 
labor was of short duration and characterized by unusually severe pains. 
The inversion occurred immediately on delivery of the placenta, the fundus 
protruding slightly beyond the vulva. The uterus was replaced and packed 
with gauze. The patient made a good recovery. 

Under ether anaesthesia one hand, shaped in conical form, is passed into 
the vagina seeking by upward pressure to return the uterus to the abdominal 
cavity, while the external hand guides and controls the movements of the 
internal. It is best, if possible, to indent the uterus in the neighborhood of 
one of the Fallopian tubes and then of the other before attempting to rein- 
vert the centre of the mass. This is the method of Noggerath and 
represents an effort to follow the direction of the muscular fibres of the 
submucous layer (Fig. 2^6). Another method is to grasp the neck or 
highest part of the constricted fundus, reducing this first and later the suc- 
ceeding portions of the mass from above downward. Sometimes direct 
pressure upon the mass works best. These methods may be tried in 
succession. Meanwhile an attempt may be made to dilate the opening 
through which the fundus has passed by the fingers of the external hand. 
Of course, the pressure should be made in the axis of the superior strait, 
or it will be injurious rather than helpful. If the placenta remains at- 
tached to the fundus it is better not to remove it, since the usual mechanism 
for the prevention of hemorrhage is not operative and profuse bleeding 
may result. 

In irreducible cases with persistent bleeding hysterectomy has been 
suggested, but anterior vaginal hysterotomy followed by reduction of the 
inversion and packing of the uterus would be more conservative and 
equally effectual. The patient is apt to be a bad subject for major surgery. 

Preventive Treatment. — This is at once suggested by the etiology of 
the condition. Lender no circumstances should any traction upon the 
cord be permitted while the placenta remains in the uterus. ]\Iisdirected 
haste and undue pressure in premature attempts to remove the placenta 
should be avoided. Uterine relaxation during the third stage should be 
avoided by the methods already described. Straining at stool, while in the 
sitting position, should be avoided. 



CHAPTER XXII 

THE PUERPERAL HEMORRHAGES 

This term is often applied in a general way to the hemorrhages of 
pregnancy, labor, and the puerperium. There is more bleeding during the 
piierperium than at other times, and it is probably for this reason that the 
term "puerperal " is used. Like many other terms, it is convenient rather 
than strictly correct. 

These hemorrhages may be divided in a general way into: i. Ante- 
partum hemorrhages, which include placenta prsevia, and separation of the 
normally implanted placenta (accidental hemorrhages), and, 2. Post- 
partum hemorrhage, of which there are several varieties. 

Let us first consider the latter; the most common of the different forms 
of hemorrhage with which the obstetrician has to deal. 

Postpartum Hemorrhage 

Definition. — The term postpartum hemorrhage is applied to hemor- 
rhage from some portion of the genital tract after delivery, as distinguished 
from antepartum hemorrhage, or hemorrhage before delivery. 

In its restricted and colloquial sense, the term postpartum hemorrhage 
means hemorrhage from the placental site, following delivery immediately, 
or within an hour or two. In its broader sense, the term includes hemor- 
rhage from the cervix, vagina, and vulva, as well as the so-called " late 
hemorrhages " that may occur hours, or even days, after delivery. 

Frequency. — It is impossible to estimate the frequency of postpartum 
hemorrhage. It varies with the character and attendant circumstances of 
labor, and, above all, with the skill of the attendant. I am accustomed to 
say to my students that the frequency with which a man meets this com- 
plication is a fairly good index of his ability as an accoucheur. To this 
rule, however, as to most others, there are occasional exceptions. In rare 
instances severe hemorrhage may occur after a labor that has been 
managed lege artis, and has apparently pursued a perfectly normal course. 
As we shall presently see, it is much less common than formerly, and it is 
less common in hospital than in private practice. 

Etiology. — Of course the immediate cause in all cases is the failure of 
the uterus to contract and retract, thus compressing the sinuses at the 
placental site. Hence it is easy to make out a long list of supposed causes 
or conditions which from a theoretical stand-point might interfere with 
uterine contraction, e.g., anaemia, debility from any cause, various general 
-diseases, and many local affections, e.g., tumors, inflammations, adhesions, 
etc. As a matter of fact one usually sees good contraction in aucTmic and 
debilitated subjects, and if labor is properly managed severe bleeding is 

459 



460 PATHOLOGY OF PREGXA^XY AND LABOR 

of the rarest occurrence. Hence it would seem that many writers in 
discussing the etiology of hemorrhage have been governed by theoretical 
considerations rather than by the results of direct observation. 

Long observation has convinced me that most cases of hemorrhage are 
due to : 

I. Prolonged or precipitate labor; 2. Improper management of the 
third stage; 3. Excessive or improper use of anaesthetics, especially 
chloroform. 

Of these three causes the last two are most in evidence at the present 
time. In former years, when women were allowed to linger for hours, or 
even for days, in the second stage of labor, hemorrhage was a common 
occurrence. The exhausted uterine muscle could no longer serve as a 
safeguard against the dreaded accident, and the mind of every practitioner 
was filled with apprehension. Since we have learned to terminate labor 
before exhaustion supervenes, serious hemorrhage is far less common. 

Strange though it may seem at first thought, too rapid deliver}^ may 
also be the cause of hemorrhage, whether the delivery is natural, as in 
precipitate labor, or artificial, as in a too rapid forceps delivery. In these 
cases there is no time for uterine retraction, the fundus does not follow 
the breech during the period of expulsion, and a large cavity is left at the 
fundus which rapidly fills with blood ; and this even before the birth of the 
child. 

A very common cause of hemorrhage is improper management of the 
third stage, and especially the premature use of Crede's method, or of other 
methods of placental expulsion. This subject is discussed in connection 
wath the management of the third stage of labor, which the student is 
advised to read carefully. 

During the period immediately following delivery nature usually allows 
the tired uterus a period of rest ; the " period of physiological repose " of 
the French writers. At this time contractions are not normally present. 
A moment's reflection is sufficient to show that anything which tends to 
favor the detachment of the placenta at this time may cause hemorrhage. 

Other causes Avhich have been adduced as favoring hemorrhage by 
causing too early placental detachment are shortness of the cord (and 
the cord may be relatively short if it is twisted two or three times around 
the child's neck), accidental seizure of the placenta by a forceps blade, 
intra-uterine manipulations during version, and late rupture of the 
membranes. 

A common cause of hemorrhage nowadays is chloroform anaesthesia, 
especially when prolonged or profound, as in operative deliveries. This 
subject is discussed in the section on the technic of obstetric operations. 

But it is not solely in obstetric surger\' that this danger exists. ]\Iore 
or less uterine relaxation often follows the use of chloroform when em- 
ployed simply to alleviate suffering. I have obser^-ed this too often to be 
deceived. ^lanv men give more than is necessarv, p-ive it bv drachms 



PUERPERAL HE.AIORRHAGES 461 

rather than by drops, give it during the intervals when they should give it 
only during the contractions. Ether has less tendency to produce relaxa- 
tion and with this agent in drop doses the maximum of safety is reached. 

All this does not mean that we should forget the humanitarian side of 
our work and allow our patients to suffer unnecessarily, but only that we 
should not permit familiarity with anaesthesia to breed carelessness. 

Among the rarer causes of hemorrhage are pelvic adhesions, and 
hbromatous degeneration of the uterine wall. Theoretically it would seem 
that these causes should produce bleeding much oftener than is really the 
case. 

Physical shock or sudden eft'ort, e.g., coughing, sneezing, or straining at 
stool, may now and then result in hemorrhage, perhaps by dislodging 
coagula at the placental site. I recall a case in which a recently delivered 
patient sustained a severe hemorrhage as the result of sitting up in bed 
shortly after delivery, contrary to my express instructions. 

That a distended bladder may prevent uterine contraction is known 
to every one and this is just as true after labor as before. During labor a 
full bladder causes delay in delivery. After labor it causes hemorrhage. 

Somewhat analogous to the hemorrhage due to the uterine exhaustion 
of delayed labor is that which follows twin labor, or labor complicated 
bv hydramnion. In these cases the uterine muscle has been weakened by 
long months of overdistention, by the ineffectual contractions of the latter 
Aveeks of pregnancy, and by the prolonged first stage so common in these 
cases. 

And finally, let the reader never forget that now and then a severe 
hemorrhage may occur when, as far as can be ascertained, none of these 
causes are present, and after a labor apparently in all respects normal. 
I well recall one occasion when, in the small hours of the morning, I was 
obliged to pack the uterus after an easy labor presenting no unusual 
features whatever. 

Bumm has suggested that in cases like this the deficiency in contraction 
is due to some congenital defect in the uterine musculature. However this 
may be, such incidents serve to remind the accoucheur that he should 
never be off his guard. 

Diagnosis. — A moderate blood loss, estimated at from 80 to 100 
grammes, is a necessary part of every labor. The man who carefully 
watches a few normal labors will soon learn to recognize any deviation 
from the usual flow. If he is in doubt, the hand at the fundus will settle 
the question. If the uterus is well contracted and hemorrhage continues, 
the bleeding is probably from the cervix, although if the case has been 
one of placenta praevia, it may be from the lower, non-contractile, uterine 
segment. These varieties of hemorrhage will be discussed later. 

P>ut the attendant must know how to recognize good uterine contraction. 
I have seen some nurses, and now and then even a physician, who appeared 
to think that if one can feel the uterus at all it is contracted. 



462 PATHOLOGY OF PREGNANCY AND LABOR 

In rare instances there may be grave hemorrhage with no flow of blood 
externally. This condition is known as concealed postpartum hemorrhage. 
I recall the case of a recently delivered woman who seemed to be doing well 
after the completion of the third stage of a normal labor. For some reason 
she was left for a few minutes alone, both by the nurse and myself. Re- 
turning to the bedside I was struck by the pallor of her face. The pulse 
also denoted extreme weakness. Inspection showed no bleeding, but press- 
ure over the fundus resulted in the expulsion of an enormous quantity of 
blood and clots. It is hardly necessary to say that the patient was carefully 
watched for a few days. Fortunately she made a good recovery. The 
lesson to be drawn is plain. Cases like this are rare but the possibility of 
their occurrence should not be forgotten. 

Treatment. — The prophylactic treatment is by all odds the most im- 
portant. Postpartum hemorrhage is usually preventable. In its severe 
forms it seldom occurs in well regulated hospitals or in the practice of 
careful men. 

A review of the causes at once suggests the proper measures of pre- 
vention. The patient should not be allowed to linger in labor until she is 
exhausted. Precipitate labor should be restrained by suitable measures, 
described elsewhere. Forceps deliver}^ should not be too rapid and during 
the expulsive stage the fundus should be carefully followed by the hand of 
an assistant. It is the custom with many physicians to give ergot as a 
routine measure as soon as the placenta has been delivered. Some have 
objected to this, but I believe it to be a wise custom. It does no harm 
and may save a life now and then. If there exist any predisposition ta 
hemorrhage, e.g., if the patient has been delivered of twins or if she has 
had much chloroform, the ergot should be given hypodermatically. It 
should also be given in this manner if she has a delicate stomach or if there 
is nausea or vomiting. The patient should be kept under observation for 
at least an hour after the expulsion of the placenta ; in suspicious cases, 
two hours. All these subjects are discussed elsewhere and need not be re- 
considered here. The student is advised to review them in connection with 
this subject. To know how to prevent hemorrhage means to under- 
stand the management of labor as well as the technic of the ordinary 
obstetric operations, and of obstetric anaesthesia. But it is well worth 
while. 

Curative Treatment. — Since we can never know in advance that 
hemorrhage will not occur we should always have at hand those means that 
experience has shown to be absolutely necessary for its arrest. These 
necessities are few in number, and to be without any one of them should be 
regarded as a serious error. 

They include plenty of hot sterile water, a fountain syringe, clean and 
new, an intra-uterine douche tube, a preparation of ergot suitable for 
hypodermic use. together with a hypodermic syringe that has recently been 
tested, and sterile gauze bandages four inches wide for packing the uterus. 



PUERPERAL HEAIORRHAGES 463 

To these should be added a volsellum forceps, or better two, a needle 
holder and needles, all of which are indispensable in case of hemorrhage 
from the cervix, and a needle for hypodermoclysis or venous infusion. 
Rubber gloves for intra-uterine manipulations should never be forgotten. 

IMany expedients more or less efficacious have been used and advised, 
but in the presence of hemorrhage there is little time for deliberation or 
choice. It is, therefore, best for the attendant to choose those which have 
best stood the test of experience, and to waste no time in their application. 
It is also advisable that a certain order should be preserved and followed in 
everv case. This order should be rehearsed, memorized, and followed, 
until the attendant cannot forget it if he will. Bad results are usually due, 
not to incompetence or to the lack of curative means, but to indecision or 
hesitation in their application. 

I am accustomed to formulate the treatment of postpartum hemorrhage 
as follows : 

1. ^Massage of the titerus and expression, or if necessary manual re- 
moval, of the placenta and other uterine contents. While the physician is 
thus employed the nurse should lose no time in giving a hypodermic 
injection of some suitable preparation of ergot. A syringe filled with ergot 
and ready for immediate use should always be at hand. 

2. If the above fails, intra-uterine injection of hot salt solution. 

3. If uterus fails to contract and hemorrhage continues, thorough 
tamponade of uterus and vagina. 

As we have already seen, the uterus should be carefully watched for at 
least an hour after delivery. If hemorrhage occurs, the relaxed uterus 
should be vigorously massaged, and as soon as contraction has been secured 
the uterus should be emptied of its contents by simple pressure upon the 
fundus or, if necessary, by the method of Crede. Let the reader remember 
as the first principle of treatment that before the hemorrhage can be checked 
firm uterine contraction must be secured. This can only be accomplished 
by emptying the uterus completely. If the uterus contains only clots, or 
if the placenta is completely detached, simple pressure over the fundus may 
be sufficient. If, however, the placenta is still in titer and there is any 
delay in its expulsion, it should be at once expressed by the method of 
Crede. Every one who takes the responsibility of caring for a woman in 
labor should learn this method, if only to use it in cases of hemorrhage. 
Its great advantage is that it enables the attendant to empty the uterus 
promptly if emergency demands, and this without the introduction of the 
hand and consequent risk of infection. My observation is that many men 
have not learned the technic of this simple manoeuvre, and therefore lose 
much time or fail altogether. In the hands of one who knows how to use 
it Crede 's method will seldom fail, but in the rare cases in which it does 
fail it is not wise, if hemorrhage continues, to waste time in prolonged 
efforts. Lender these circumstances the gloved hand should be introduced 
and the placenta removed. Gloves should be worn in all these cases, but 



464 



PATHOLOGY OF PREGXA^XY AXD LABOR 



they are especially useful when hemorrhage is profuse and time for disin- 
fection of the hands is lacking. \\'hile these things are being done the 
nurse should lose no time in administering a hypodermic injection of some 
suitable preparation of ergot. If no competent nurse is present the physi- 
cian can give the injection of ergot with one hand, while he holds the fundus 
with the other. In these cases the subcutaneous use of ergot is the only 
rational one. Its use by the mouth is apt to nauseate the patient. Women 
who have lost much blood are especially prone 
to vomiting. ^Moreover, time is precious, and 
the hypodermic method is much more prompt and 
efficient. 

Firm massage of the empty uterus usually 
secures good contraction. If, however, this is not 
the case, the physician proceeds at once to the next 
step — the intra-uterine injection of hot sterile 
water. The fountain syringe, already filled, hangs 
in a convenient place, and the douche-tube has 
been sterilized with the other instruments and 
accessories. The tube is carried into the vagina 
under the guidance of the finger, and the operator 
should make sure that the tip passes through the in- 
ternal OS. It is unnecessary and dangerous, how- 
ever, to pass it to the fundus, as is sometimes 
advised. The effect is no greater, and there is 
danger of injecting fluid, or washing clots, into 
the uterine sinuses. The best tube is of glass, 
about as large as the finger, perforated at the 
sides, but not at the end, which should have a 
bulb-like enlargement. Such a tube can be easily 
felt through the abdominal wall, and is not likely 
to penetrate the uterine w^all, or enter a sinus. 
Small metal tubes are obviously unsuitable (Fig. 
277). The solution should be in the neighbor- 
hood of 120°, i.e., about as hot as will permit 
the immersion of the hand for a minute or two. 

There are few cases in which the emptying of the uterus, followed by a 
hot douche, fails to arrest the hemorrhage. In these cases the uterus 
should be tamponed. The most convenient material for this purpose is a 
sterilized gauze bandage four inches wide. A few such bandages should 
always be a part of the equipment of the obstetrician. The tamponade 
may be either manual or instrumental. In the latter months of pregnancy 
and at term the manual method is much more satisfactory and thorough. 
At this time the cervix can be pushed down to the vulva and the gauze 
introduced with two fingers. In the manual method, assistants and instru- 
ments are not necessary and time is saved, a matter of A'ast importance. 




Fig. 277. — Intra-uterine 
douche-tube, natural size, 



PUERPERAL HE^IORRHAGES 



465 



In hemorrhage after abortions the instrumental method may suffice. 
In the latter months of pregnancy and at term, the manual method is the 
only method which can be relied upon. Working in a cavity so large as the 
fuli-temi uterus, the hand or half-hand is much more satisfactory, since 
the sense of touch enables the operator to tell just where to place the gauze, 
^lanv a nook and corner must of necessity be neglected if only the dressing 
forceps are used. The external hand at the fundus guides and controls 




Fig. 278. — Uterus tamponed by the manual method. 

the internal one, and thus the operator has at all times perfect and efficient 
knowledge of what is going on within. Merely to push a few pieces of 
gauze into such a cavity with a long dressing forceps is to invite failure. 
The secret of the control of postpartum hemorrhage is to thoroughly 
tampon the uterine cavity by the manual method before it is too late. As a 
rule the procedure is not very painful, but if the patient is highly nervous 
and sensitive a few drops of ether may be given. Theoretical objections 
have no weight with those who know from experience what this method 
will do. It is astonishing that for so many centuries women were allowed 
to bleed to death before Diihrssen conceived the idea of applying to this 
emergency the ordinary rules of surgery. 
30 



466 



PATHOLOGY OF PREGNANCY AND LABOR 



The accompanying illustration (Fig. 278) shows better than words 
can tell just how to pack the uterus. The great essential is that the first 
piece of gauze should be carried to the fundus. After the uterine cavity is 
fairly well filled additional gauze should be carried up in front, behind, and 
on both sides of the central mass until the limit has been reached. All 
this time the external hand makes firm counter-pressure. It is my observa- 
tion that the failure of some men to attain success with this procedure is 
due to the fact that they do not pack with sufficient thoroughness. When 
the uterine cavity has been filled, the vagina should be packed and a 
T-bandage applied. If the packing has been properly done, the uterus soon 
attains a stony hardness. There is no uterine hardness like that of a 
tamponed uterus except in the case of the so-called accidental hemorrhage 
when the antepartum uterus is filled with blood that cannot escape. 

The packing should be 
slowly and carefully 
withdrawn at the end 
of from tw^elve to 
eighteen hours. I have 
never known the bleed- 
ing to recur, nor do I 
believe that it will re- 
-cur, if the work has 
been properly done. 

A method recently 
devised by IMomburg is 
the constriction of the 
upper abdomen by a 
piece of rubber tubing. 
The constricting tube 
is tightened until the 

Fig. 2 79. — Instrumental compression of the abdominal aorta (Gauss). i • i.-l^ r t 

artery disappears. That this method cannot be entirely without risk 
seems plain. That it cannot often be necessary is equally plain. I do not 
think the method will survive. 

A better way of compressing the abdominal aorta is that of Gauss, 
illustrated in Fig. 279. It is plain that by this method the pressure can 
be far better guided and regulated, and it is claimed by its advocates that 
injury to the heart, intestines and bladder (these have been noted in the 
use of the Momburg belt) are impossible. 

I have not found it necessary to use either of these methods, though I 
can see no objection to the use of the Gauss compressor. 

The above measures, if instituted while the patient still has a fairly good 
pulse, are, in my experience, uniformly successful. But they must be 
carried out in their proper order and without delay. Hesitation and 
indecision are responsible for most bad results. 




PUERPERAL HE^IORRHAGES 



467 



\Miile it is not desirable to lose time in experimenting with the many 
methods that have been devised for stopping hemorrhage, there are some 
that are too valuable to be passed without mention. 

In case of great emergency the clenched fist may be used as a tampon, 
after the manner illustrated in the accompanying cut (Fig. 280). This is 
an efficacious method and especially adapted to those cases in which the 
phvsician is unexpectedly called to one of those severe hemorrhages 
occurring within a few moments of delivery. 

A method advised bv Fochier is the so-called pubiomanual compression 




Fig. 280. — The closed fist as an emergency tampon. 

(Fig. 281 ) . In this method the strongly depressed and anteverted uterus is 
compressed against the pubis by means of one hand placed above and behind 
the uterus. The other hand is made to prolong the plane of the pubis in 
front, and both hands are then strongly approximated. Thus the uterus is 
compressed along its entire length. This method, it will be noted, does not 
require the introduction of the hand into the uterus. 

Either of these methods may be useful in an emergency. Neither is as 
satisfactory as a thorough tamponade of the uterine cavity. 

Compression of the aorta against the spinal column in the neighbor- 
hood of the umbilicus causes an anaemia of the uterus, which reflcxly 



468 



PATHOLOGY OF PREGXA^XY AND LABOR 



stimulates to contraction. ^Moderate pressure is sufficient. It must be con- 
tinued for five or ten minutes to prove effectual. It is not necessary to 
cause pain. The pulsations of the aorta are easily felt through the relaxed 
abdominal wall, and the procedure may be carried out by any intelligent 
bystander while the physician is busy with the methods already described. 
The introduction of ice into the uterus was formerly a favorite method, 
but ice is not sterile, and is no more effective than hot water. Ice ex- 
ternally, an ice-bag, or still better a piece of ice, applied over the fundus, is, 
however, an excellent method of maintaining contraction, once it has been 




Fig. 2l 



Posterior cervical lip. 
-Bimanual compression of atonic uterus. 



secured. It is especially useful when the uterus has not been packed, or 
when one is not confident that the packing has been properly done. 

\K\th. the securing of good uterine contraction the troubles of the 
attendant are not over. He may be called upon to treat the acute ansemia 
that follows severe hemorrhage. There need be no trouble about recog- 
nizing it. The evidences are all too plain. The face is blanched and 
drawn and the features are sharply outlined. The patient seems to have 
grown thinner and older in an hour. The lips are as colorless as the 
cheeks. The temperature is normal or sub-normal and the skin is bathed 
in a clammy sweat. 

The pulse is not rapid, as is usually stated by those who pursue their 
investigations in library or laboratory rather than in hospital. It does not 
often exceed lOO to no. It is, however, compressible and may even 
become for a time imperceptible. The patient is perfectly conscious, but 



PUERPERAL HEMORRHAGES 



469 



betrays a certain nervous restlessness which is very characteristic. Thirst 
is a prominent symptom : in bad cases there may be marked dyspnoea, the 
air hunger of the Germans. The patient gasps for breath and asks that win- 
dows be opened. The picture is appalHng, especially to the inexperienced. 
Happily things are not always as bad as they seem. Many patients 




Fig. 282. — Saline infusion. 

recover when apparently almost beyond hope. Therefore hope should not 
be given up while life lasts. 

What is to be done? The first indication is to restore the volume of 
the circulation, thus keeping up the mechanical action of the heart. 
Theoretically the infusion of salt solution into a vein is the best treatment, 
but it is not always easily carried out (Fig. 282). The veins are colorless 
and collapsed, and I have seen an obstetrician of large experience work 



470 



PATHOLOGY OF PREGNANCY AND LABOR 



for a long time trying to find a vein in the arm, the patient in the meantime 
losing not a little blood from the dissection. Hypodermoclysis, the injec- 
tion of the solution under the skin, is easy and quite effective. The best 
site for the injection is the loose cellular tissue beneath the breasts 
(Fig. 283). 

It should have been previously disinfected in preparation for this 




Fig. 283. — Hypodermoclysis. 



emergency. I recall the case of a hospital patient who developed a sub- 
mammary abscess as the result of the neglect of this precaution. A'ery 
useful, too, is the high colonic injection of hot salt solution. The solution 
is allowed to run slowly into the bowel through a long rectal tube. The 
mucous membrane sucks this up greedily and very often not a drop is 
returned. The patient should be kept perfectly quiet with the head low, 



PUERPERAL HEMORRHAGES 471 

and oxygen administered, if obtainable. Physiologists have disputed the 
efficacy of oxygen on theoretical grounds, but it certainly relieves the 
patient and probably does good. Heat externally, in the form of hot 
blankets, hot bottles to the extremities, hot water-bags, etc., contributes to 
recovery and is very grateful to the patient. It is probably better to 
withhold nourishment for a short time, as these patients have a strong 
tendency to vomit whatever is taken into the stomach, and vomiting is 
highly undesirable at this time, not only weakening the patient, but perhaps 
causing a renewal of the hemorrhage. Small pieces of ice may be held in 
the mouth to relieve thirst. As soon, however, as the patient is able to 
retain it, it is highly important that she take liquids or liquid nourishment in 
small quantities and at short interv^als. Weak tea or coffee, wine and 
water, broths, gruels are all eligible, quantity being at this time perhaps 
more important than composition. 

Of the drugs that have been used I believe that morphine hypo- 
dermically in small doses, ]{& to yg gr., is by all odds the best. It seems 
to relieve the cerebral anaemia, which is the cause of many unpleasant 
symptoms, to quiet the patient's restlessness and make her much more 
comfortable, and to improve the character of the pulse. If the condition is 
complicated by shock, strv^chnia, hypodermically, ]io to j^o gr., may be 
beneficial. On the whole, however, I do not think that for cases of pure 
hemorrhage it is advisable to whip up the heart by stimulants. 

Hemorrhage from the Cervix 

Hemorrhage from the cervix is a subject strangely neglected in many 
works, but one deserving careful attention. Lack of appreciation of its 
importance is doubtless due to the fact that tears of the cervix sufficiently 
extensive to cause hemorrhage occur as a rule only after difficult operative 
deliveries. In a long succession of normal cases and easy forceps deliveries 
it will not be encountered, and thus the practitioner may learn to regard 
it as an obstetrical curiosity, or even cease to believe in its existence. 

It is no doubt true that women do not often die of hemorrhage from 
the cervix, but that fatal results do occasionally occur is beyond doubt, 
and in many unrecognized cases the patient loses so much blood that her 
convalescence is retarded and her subsequent health affected. 

Etiology. — The cause is to be found in operative delivery when prac- 
tised before complete dilatation of the cervix, and especially in those cases 
in which the foetus is of unusual size. In my experience it is more 
common after high forceps operations than versions ; probably because 
in versions the operator is obliged to dilate the cervix before he can 
complete the operation. The etiology has, as we shall presently see, a 
most important bearing upon the treatment. 

Clinical History and Diagnosis. — The possibility of cervical hemor- 
rhage should be borne in mind in all high and mid forceps operations and 
in all versions. In other words, in all cases in which delivery is accom- 



472 PATHOLOGY OF PREGNANCY AND LABOR 

plished before complete dilatation and retraction of the cervix. Too often 
the operator contents himself with the palpation of the fundus, and finding 
the uterus contracted, leaves unnoticed a hemorrhage which, though not 
great, is persistent, and if not arrested, capable of working great harm. 

There is no more beautiful exercise in obstetric diagnosis than the 
differentiation between hemorrhage from the cervix and hemorrhage from 
the cavity of the uterus. 

As already noted, the great and characteristic point of difference is that 
in true postpartum hemorrhage the uterus is relaxed, while in hemorrhage 
from the cervix alone it is contracted. The corpus uteri, it is true, may 
be well contracted in hemorrhage from the lower uterine segment after 
placenta prasvia, but it is impossible for this complication to escape the 
notice of any competent practitioner. 

In hemorrhage from the cavity the bleeding is much more copious and 
is venous in character, while from the cervix it is arterial, bright red, a 
trickle rather than a stream. In some cases, if the cervix is exposed, a 
spouting artery may be seen. 

Hemorrhage from the cavity of the uterus often, indeed usually, 
begins before the expulsion of the placenta, while hemorrhage from the 
cervix, unless very severe, is not noticeable until after the expulsion of the 
placenta, the latter acting as a tampon. 

The history of the case often suffices. Plemorrhage from the cervix 
does not occur after normal labors or low forceps operations. 

Ocular demonstration is afforded by drawing down the cervix with 
tenacula. In these cases the cervix is much distorted, but with care one 
can always tell from which side the bleeding comes. It is usually the left. 

After delivery, and especially after difficult operative deliveries, the 
cervix is hardly recognizable as a cervix. The anterior lip, enormously 
swollen, hangs down, obscuring the posterior lip, which is much smaller, 
and lying far back, almost out of sight. 

Treatment is either prophylactic or curative. As usual the prophylactic 
is the most important. Hemorrhage from the cervix, like other forms of 
hemorrhage, can usually be avoided. 

Prophylactic Treatment. — The cervix should be thoroughly dilated, 
and not only dilated but temporarily paralyzed, before every high or mid 
forceps operation, and before every version. Aversion for placenta prsevia, 
of course, constitutes an important exception to this rule. The importance 
of complete cervical dilatation before the forceps operation and before 
version has been discussed in connection with those subjects. Bad tears 
of the cervix are less likely to occur as the result of manual dilatation than 
of the forcible dragging of the head through an imperfectly dilated cervix. 

My experience has been, though I have never seen it in print, that one 
is much less likely to tear the cervix with the axis-traction forceps than in 
using the ordinary model, and this is what would naturally be expected. 

It is a fact not generally known, or at least seldom emphasized, that in 



PUERPERAL HE:^I0RRHAGES 473 

premature labor the cervix dilates more slowly. In these cases manual 
dilatation is not always successful and slow^er measures, e.g., the tampon 
or the bags of de Ribes, are to be recommended, if time permits. 

The dangers of rapid dilatation and extraction in placenta praevia are 
discussed elsewhere. 

Curative Treatment. — Strong pressure upon the fundus brings the 
cervix to the vulva, where it is easily accessible to sight and touch. Each 
lip, anterior and posterior, is seized by a volsellum forceps and put on the 
stretch bv moderate traction. This traction not only enables one to deter- 
mine the size and location of the tear, but for the time being it stops the 
hemorrhage. Traction upon the cervix then is the first step in all cases. 

The next step is suture of the cervical tear. It is only necessary that 
the operator should not lose his presence of mind. The operation itself 
is easy. Some care is needed, it is true, in locating and seizing the pos- 
terior lip. It is not possible to photograph the actual conditions. Two 
or three sutures, preferably of silkworm gut, usually suffice. The first is 
passed near the apex of the tear ; first, through the posterior lip from 
without inward, and then through the anterior lip from within outward 
and tied outside the canal, previously shown. If the operator has not 
placed the first suture high enough, he will at least find it very convenient 
as a traction suture by means of which he can fix and draw down the 
cervix while placing another suture above the first. Removing the sutures 
two or three weeks later, one finds them hanging loosely in the vagina, 
and is often astonished to see what a good result has been obtained from 
the stand-point of plastic surgery. 

One or two hints to the beginner : 

Xever be without the necessary instruments for repairing the cervix. 
They are the same as those needed for perineorrhaphy, with the addition 
of one, or better, two, strong volsellum forceps. Though not often needed, 
when they are needed they are indispensable. 

Always think of cervical hemorrhage after forceps operations and 
version, and if bleeding continues when the uterus is contracted. 

Remember that neither ergot nor the tampon is of much service in this 
form of bleeding, but that the suture is prompt and certain. Do not waste 
your time ! 

Some care is needed to locate and seize the posterior lip. The relations 
of the two are diagrammatically represented in Fig. 270. It is not prac- 
ticable to photograph the actual conditions. 

Late Hemorrhages 

When uterine contraction has been maintained for from one to two 
hours after delivery postpartum hemorrhage in its ordinary form is no 
longer to be feared. The attendant should not forget, however, that it is 
possible for severe bleeding to occur several hours after delivery as the 
result of profound mental shock, or of some physical exertion. 



474 PATHOLOGY OF PREGXAXCY AND LABOR 

Now and then a severe hemorrhage occurs two or three days after 
dehvery. Such a hemorrhage is almost always due to the retention of a 
comparatively large piece of placenta which has remained attached to the 
uterine wall. Of course, involution cannot proceed normally beneath the 
placenta. The sinuses remain open. When the placenta is finally detached, 
dangerous bleeding may result, as I have myself seen. 

But severe bleeding at this time is rare. ]\Iuch more often the hemor- 
rhage, though prolonged, is moderate in quantity ; an increase and pro- 
longation of the ordinary lochia rubra. This may be due to the retention 
of small fragments of placenta, too small to be appreciated by the examin- 
ing finger, or again, it may be due to subinvolution or retro-version. 

Treatment. — Something may be done in the way of preventing these 
hemorrhages by carefully adhering to the rules for the proper management 
of the third stage, given in the chapter on normal labor, and in the avoid- 
ance of undue haste in the delivery of the placenta, especially the too early, 
or non-indicated, employment of the Crede method. 

Profuse hemorrhage, resulting from the separation of a large piece of 
placenta, is best treated by tamponing the uterus, applying ice externally, 
and administering ergot. If the placental mass is still in utero, it should, 
of course, be removed by the finger. 

Minor degrees of hemorrhage should be treated by rest in bed, the 
application of an ice-bag to the fundus, and the continued use of small 
doses of ergot. A favorite prescription of mine at this time is a mixture 
of ergot and hydrastis, equal parts, twenty or thirty minims three times 
a day. 

It is better not to use the curette before the end of the fourth week. 
The danger of embolism is by no means negligible, and if infection happens 
to be present, the consequences may prove serious. Subinvolution and 
retro-version should be treated by the methods elsewhere described. Iron 
in some form easily retained and quickly assimilated, e.g., iron tropon, 
or peptomangan, should be given and a liberal diet allowed. 

Placenta Pr.evia 

Definition. — Normally, as we know, the placenta is implanted near 
the fundus, either upon the anterior or posterior wall. When it is located 
near the cervix we speak of a low implantation of the placenta. AMien it 
borders upon, or partly or entirely covers, the internal os, the condition 
is known as placenta pr^evia (Fig. 284). 

Varieties. — There are four varieties of placenta praevia : 

Central or complete, in which the placenta completely covers the 
internal os, as the latter is accessible to the examining finger. 

Partial, in which it but partly covers the os. 

^Marginal, in which the placenta, while implanted wholly or partly in 
the lower uterine segment, does not extend beyond the border of the 
internal os. 



PUERPERAL HEMORRHAGES 



475 



Cases of lateral placenta pr?evia are often referred to as cases of low 
implantation. 

Frequency. — There is much difference of opinion as to the frequency 
of placenta pra^via. It has been variously estimated as from one in two 
hundred to one in one thousand. IMy own opinion is that the former 
estimate is much nearer the truth than the latter ; I believe that many cases 
of marginal and lateral implantation pass unrecognized. Doubtless many 
cases of abortion in the first half of pregnancy are cases of unrecognized 
placenta pr?evia. 

Cragin reports that in 25,000 cases at the Sloane Maternity Hospital 
there were 223 placenta prsevia, or one in 112. Of course many of these 
Avere sent to the hospital because 
they were regarded as emergency 
cases, and this report therefore repre- 
sents a somewhat greater frequency 
than obtains in private practice. 

Etiology. — This is still largely a 
matter of speculation. The old idea 
that the ovum falls from its attach- 
ment or is detached by mechanical 
means is no longer tenable. As 
A\'illiams aptly points out, gravity 
cannot be adduced as a factor, since 
owing to the marked anteversion 
that characterizes normal pregnancy 
the fundus is, during the early 
months, lower than the cervix. 

What favors the arrest of the 
ovum in its usual location upon the 
anterior or posterior wall near the 
fundus we do not know, except that 
decidual development in the cornua 
is slight. We do know, however, 
that a degenerated endometrium 
may prevent its arrest, and this knowledge forms the basis of the most rea- 
sonable and helpful hypothesis. It is highly probable that in a great 
majority of cases the condition is due tO' a preexisting endometritis. This 
was first pointed out by Strassman in 1901, and is confirmed by clinical 
experience, as endometritis may either prevent the implantation of the 
ovum in its usual position near the fundus, or, by limiting the blood 
supply of the decidua, make it necessary for the placenta to widely increase 
its area of attachment in order to secure a sufficient blood supply for the 
foetus. In this way it may come to encroach upon the lower uterine zone. 

The studies of Hofmeier and Kaltenbach seem to indicate that the 
development of the placenta from that part of the chorion, which is 




Fig. 284. — Normal and abnormal placental sites. 



476 PATHOLOGY OF PREGNANCY AND LABOR 

attached to the decidua reliexa, may be an occasional cause, and the possi- 
bility that it may in some cases be due to structural anomalies such as 
malformations, tumors, low implantation of the Fallopian tubes, etc., is 
not to be denied. These causes, however, are to be regarded as exceptional. 

In the great majority of cases careful questioning will elicit a history 
of abortion, subinvolution, infection, or some other cause of endometrial 
degeneration. In some cases there is a history of endometritis antedating 
a first pregnancy. ]\Iultiparity is usually given as a predisposing cause 
since the condition occurs about ten times as frequently in multiparse, but 
this is probably true only in so far as the latter are more subject to the 
usual causes of endometritis, e.g., subinvolution, sepsis, abortion, etc. 
Many primipar^e it is true have endometritis, but in such cases conception 
is less likely to occur. 

It is claimed by Keilman and others that the placenta is sometimes 
developed upon the upper part of the cervix, and it has been shown that 
after a first pregnancy the mucous membrane of the cervix may become 
so m.odified as to be practically identical with that of the body of the 
uterus. We have already learned that there are many who believe that 
the lower uterine segment is formed either wholly or in part from the 
expanded upper portion of the cervical canal. 

Bumm is of the opinion that since the internal os is smaller than the 
fertilized ovum, and is moreover filled with a plug of mucus, there is no 
reason why it should not be arrested at this point. 

After all that which is of most interest to the practitioner is that multi- 
parity is a predisposing, and endometritis an exciting, cause. Both facts 
aid in the diagnosis and the second fact suggests the prophylactic treatment. 

Clinical History and Diagnosis. — Assuming the existence of preg- 
nancy, one might almost sum up the diagnosis of placenta prjevia in two 
words, " painless hemorrhage." Let me cite an illustration. If in the 
early months of pregnancy hemorrhage occurs and is accompanied by pain, 
both the patient and her family are much alarmed and the physician is 
summoned at once. But it is the pain rather than the bleeding that is the 
source of alarm. If in the case of a patient farther advanced in pregnancy 
a slight or moderate, but painless, hemorrhage occurs, it may excite little 
attention, simply because it is not accompanied by pain. In the first case 
the symptoms indicate an impending or actual abortion, in which, under 
proper management, the prognosis is almost uniformly good, while in the 
second case they strongly suggest placenta praevia, always a dangerous 
condition. 

The first symptoms of placenta praevia, then, are often unnoticed or dis- 
regarded by the patient. Hence the importance of warning our patients 
that any bleeding whatever during pregnancy is unnatural and should be 
reported at once. The first hemorrhage usually occurs during the seventh 
or eighth month, though I have known severe bleeding to occur at six 
months, and a case which proved fatal in the fifth month, and in which the 



PUERPERAL HEAIORRHAGES 477 

diagnosis was confirmed by autopsy, has been reported. In this case, which 
I personally investigated, a severe hemorrhage, which proved rapidly fatal, 
followed sexual intercourse. In rare cases there is no bleeding until the 
beginning of labor. 

The blood is bright red in color from arterial admixture, and is not 
to be confounded with a dirty brownish-red discharge common in certain 
cases of decidual endometritis. The quantity varies. The first hemorrhage 
is usually slight, but it may be fatal. In most cases there is sufficient 
^varning. ^Manipulation of the parts in digital examination may consider- 
ably increase the hemorrhage. Cave! 

A free and painless discharge of bright red blood from the cervix dur- 
ing pregnancy is practically sufficient to verify the diagnosis, even in those 
early cases in which the cenax will not admit the finger, and in which 
physical examination, both external and internal, is as yet unsatisfactory. 
In the eighth and ninth months, however, certain physical signs develop 
Avhich furnish important confirmation. 

External Sigxs. — In patients with a thin and relaxed abdominal wall, 
the location of the placenta may sometimes be defined, and when it is 
located anteriorly, its convex edge may be traced as a resisting ring 
(Polakl. The experienced examiner is often struck by the fact that the 
head is felt at a somewhat higher level than usual. This is due to the fact 
that its entrance into the pelvic cavity is prevented by the placenta. For 
the same reason malpositions and malpresentations are more common than 
in normal cases. Palpation of fetal parts at the inlet may be rendered 
difficult. 

Internal Signs. — In the latter weeks of pregnancy the cervix will be 
found somewhat enlarged from the increased vascularity of the parts 
and there may be unusually marked pulsation of vessels in the vaginal 
v^ault. These traditional signs of the text-books are by themselves of no 
great importance. Bogginess of the vaginal vault, however, and in par- 
ticular inability to feel the head through the vagina when it can be palpated 
externally, are symptoms of the greatest value. In cases of placenta prsevia, 
the cervax during the latter weeks of pregnancy is softer and more dilatable 
than in uncomplicated cases, and it is usually easy, even in primiparge, to 
pass the finger through the internal os and feel the rough and granular 
maternal surface of the placenta. The competent accoucheur, however, 
should be able to dispense with this method of diagnosis, which obviously 
increases the risk of infection, and, as I have observed, distinctly Increases 
the bleeding at a time when the mother needs every drop that can be saved. 

The history of the case has some value. As we have already seen mul- 
tiparity Is a predisposing cause, and there is usually a history of previous 
uterine disease. Moreover, the condition may recur in succeeding preg- 
nancies. I recall one case In which three successive labors were com.pli- 
cated by pkcenta praevia, severe bleedlnsf occurring In each case. 

If the hemorrhage Is severe the well-known evidences of acute aucxmla 



478 PATHOLOGY OF PREGNANCY AND LABOR 

are not long absent. Blanching of the face and lips, smallness and rapidity 
of the pulse, faintness, dizziness, etc., afford unmistakable evidence of the 
gravity of the condition. To wait for these symptoms, however, is 
inexcusable. 

It is plain that the diagnosis of placenta praevia is not difficult. Mis- 
takes are due to carelessness. The lesson is plain. 

The principal symptom of placenta prsevia is hemorrhage. How is the 
hemorrhage produced? As already stated, the placenta is normally 
attached near the fundus. In discussing the physiology of labor we have 
seen that the uterus during labor is divided into two parts, an upper con- 
tractile, non-distensible part above the ring of Bandl, the corpus uteri ; 
and a lower distensible part, which becomes thinner and more distended 
during the passage of the foetus, the lower uterine segment. 

When the placenta is attached above the ring of Bandl, as in normal 
cases, it does not ordinarily become separated until the third stage of labor. 
A moment's reflection, however, will show that when it is attached to the 
lower uterine segment, which during labor becomes greatly distended, 
separation of the placenta must occur as soon as uterine contractions set in. 
The area of the placenta remains the same, but the area of the underlying 
uterine wall becomes much extended. The vessels are torn across, bleeding 
is inevitable. With each contraction the area of separation is increased 
and the bleeding becomes more profuse. 

Contrary to a very prevalent opinion, however, the bleeding is most 
profuse, not during a contraction, but immediately after. It is not the 
contraction that, directly causes the bleeding, but the placental separation 
induced by the contraction. During the contraction the vessels at the 
placental site are compressed by the presenting part, but as the uterus 
relaxes the hemorrhage is renewed. 

Prognosis. — It cannot be too strongly emphasized that the maternal 
prognosis in placenta prsevia depends largely upon the treatment. In other 
words, it depends upon the skill, confidence, and prompt action of the 
physician. 

Some writers have reported a mortality of 25 per cent, or more, but 
such a rate could be the result only of gross incompetence or neglect. 

The central implantations are the most serious, but there are exceptions 
to this rule. Let no one imagine that the prognosis is necessarily favorable 
in marginal, or even in lateral, implantations. As Bumm has pointed out, 
the amount of hemorrhage depends upon the size and location of the 
severed vessels, and may sometimes be moderate in the central variety and 
quite severe in other forms. Hence the supposedly mild cases should be 
watched as carefully as those apparently more severe. 

The prognosis is, of course, bad in neglected cases or in those that have 
been subjected to expectant treatment until the patient has become exsan- 
guinated. The most difficult cases to treat are those in which the cervical 
canal is preserved and the cer^ax hard. Fortunatelv these cases are rare. 



PUERPERAL HE^IORRHAGES 479 

The skilled obstetrician should not lose more than 3 per cent, of his 
cases, provided he has charge of them from the beginning. In no depart- 
ment of obstetrics does more depend upon the personal efforts of the 
physician than in placenta previa. The prognosis is best in a well- 
conducted maternity hospital. 

The fetal prognosis under all forms of treatment is bad ; perhaps 50 
per cent. This is due not only to the placental separation, but to the fact 
that most labors are either premature or operative, or more commonly 
both. Ordinarily, of course, the gravity of the fetal prognosis is pro- 
portionate to the amount of placental detachment, and is greatest in cases 
of central implantation. 

Treatment. — In considering the treatment of placenta prasvia a sharp 
line is to be drawn between the cases in which the cervix is dilated or 
easily dilatable, and those in which this is not the case. The first class 
comprises the great majority. As a rule bleeding does not occur until 
late in pregnancy, and most of the cases are multiparse. In the latter, 
as we have already seen, one or two fingers can usually be passed through 
the internal os at this time without difhculty. Of course this of itself would 
not make dilatation easy, but the cervix in placenta prsevia is, owing to its 
vascularity, softer and more easily dilatable than at other times. Even in 
primiparae, the cervix is usually soft and easily dilatable, the cervical canal 
is nearly or quite obliterated, and dilatation is easily effected. Then, too, 
the condition tends to cause premature labor and it often happens that 
some degree of dilatation has already been attained by the efforts of nature. 

All this is fortunate. If it were not for this, placenta praevia, serious 
enough as it is, would be far more formidable. 

Let us then take up first the treatment of one of these typical cases of 
placenta praevia. The first thing to do is to rupture the membranes. This 
of itself is sufficient, in mild cases, to stop the hemorrhage. The escape 
of the amniotic fluid is followed by more vigorous uterine contractions, 
and the presenting part descends and compresses the placental site. Uterine 
retraction diminishes the bleeding area, and the placenta is drawn up with 
the retracting lower segment, further separation from the uterine wall being 
thus avoided. In many cases, especially the lateral and marginal ones, 
nothing more is required. Pressure upon the fundus now aids materially 
by fixing the presenting part in the lower uterine segment, thus increasing 
the compression of the bleeding surfaces, and if the foetus is premature 
and small, as is usually the case, pushing the head well down into the 
pelvis and thus permanently arresting the bleeding. Labor may then be 
hastened by pituitrin or the forceps, or the case may be left to nature. 

But unfortunately all cases are not as simple as this. The procedure 
fails to arrest the hemorrhage, or the bleeding is free, and one does not 
feel justified in waiting. What is to be done? 

In these cases it was formerly the custom to use the tampon, and this is 
still the practice with many. In my opinion it is a mistake, and has been 



480 PATHOLOGY OF PREGXAXCY AXD LABOR 

in large part responsible for the mournful results sometimes obtained. 
The tampon, as we shall presently see, has a field of usefulness in certain 
early cases, but in the cases now under discussion it is entirely out of place. 
As usually applied, it is a mere pretense, and even if the application is made 
lege artis, it affords no security that hemorrhage is not going on behind 
the tampon. ^Moreover, the necessary manipulations vastly increase the 
danger of infection. If the cervix is dilated or easily dilatable, as it is in 
the vast majority of cases, no time should be wasted on the tampon. A 
tampon, in order to be successful, must make pressure on the bleeding 
surfaces. Such a tampon we have in the half breech of the foetus. Bipolar 
version is in these cases no more difficult than is a thorough tamponade, 
and when the version is complete the danger to the mother, provided the 
version has been perform.ed early enough, is practically over. 

Technic. — The patient is placed upon a table. It is highly important 
that too much time should not be consumed, and the operator should there- 
fore work under the most favorable circumstances. Ether, or preferably 
ether oxygen, should be the anaesthetic. It is folly to subject the patient 
to the additional danger of chloroform in these cases. Xo attempt at 
complete dilatation of the cervix should be made as in ordinar\^ versions, 
but with half -hand, or if necessary the whole hand, in the A'agina two 
fingers should be passed into the uterus and the head pushed to one side. 
The external hand at the fundus strongly depresses the foetus striving to 
bring a foot or knee within reach of the internal fingers. It may be neces- 
sary to pass the half-hand within the uterus, but unnecessary stretching 
of the cervdx should be avoided. When a knee has been brought to the 
vulva one may be certain that the version is complete. The presence of 
the half breech in the cervix causes vigorous uterine contractions, and thus 
the bleeding surfaces are doubly compressed. ^Moderate traction upon the 
foot, together with pressure upon the fundus, serves to keep up these 
contractions, and to maintain this compression. X^o attempt at immediate 
extraction should be made, however, unless the cervix happens to be 
already well dilated. Such attempts are highly dangerous to the mother. 
I recall a case in which death followed in about two hours. The post- 
mortem showed a cervical tear extending far up into the lower uterine 
segment. In these cases the cervix is soft (some one has compared it to 
wet blotting paper), and furthermore it is very vascular and bleeds freely. 

When the half breech has been brought into the cervix the bleeding 
ceases and the mother is, for the time at least, out of danger; that is, of 
course, if she has not lost too much blood before the operation. The 
operator now has control of the situation and can proceed with all com- 
posure. He should not attempt to drag the foetus through the cervix, 
until this can be done without the use of much force. 

After delivery special care should be taken to prevent further blood 
loss, and if there is much tendency to relaxation the uterus and vagina 
should be promptly packed. In these cases the hemorrhage is from the 



PUERPERAL HE:\I0RRHAGES 



481 



lower, non-contractile portion of the uterus, and is not always amenable 
to the usual measures of treatment. 

Attempts have recently been made to lessen the fetal mortality in 
placenta pr^evia by the use of the de Ribes bag or some one of its modifi- 
cations. Fig. 28-, shows how the bag compresses the placental site while 
at the same time dilating the cervix. It is as yet too early to determine the 
value of this method. Its trial is permissible in maternity hospitals or in 
the hands of obstetric experts in suitable cases. IMore technical skill is 
required than in cases in which the bag is used for simple dilatation and 
without reference to the prevention of hemorrhage. I believe that its 




Fig. 285. — The de Ribes bag in placenta previa. 

general adoption w^ould result in an increase in the maternal mortality 
with no corresponding diminution in that of the foetus. 

Theoretically this method is ideal, but in practice it has its disadvan- 
tages. It presupposes considerable technical skill on the part of the 
operator, who must watch the case carefully for hours at a stretch, per- 
haps ten or twelve hours. If the bag slips out without his knowledge, 
there may be severe bleeding behind it, and changes of bags are necessarily 
accompanied by more or less hemorrhage. If too strong traction is made, 
the softened cervix may tear. Considerable manipulation is necessary, and 
this increases the danger of infection as well as of hemorrhage. 

It seems obvious that this method should be confined to hospital cases 
in which the child is viable and the mother has lost little blood. In such 
31 



482 PATHOLOGY OF PREGNANCY AND LABOR 

cases it has been claimed that the fetal mortality can be reduced more than 
one-half. If this statement shall prove correct it will be a strong additional 
argument for sending cases of placenta prsevia to a hospital. 

L^p to this time we have assumed that the cervix is dilated or easily 
dilatable. But this is not always the case. Placenta prsevia may occur in 
the sixth, seventh, or eighth month, and in cases in which the cervical 
canal has not been taken up, or, at all events, what is left of the cervix is 
hard and resistant. As a rule, these cases occur before the child is viable, 
i.e., during the sixth and seventh months. They should be regarded and 
treated as cases of inevitable abortion. Li these cases the tampon is of 
great service. The membranes should be ruptured and the patient care- 
fully watched for a short time. If the bleeding ceases, nothing more may 
be necessary. If not, the vagina should be tamponed, as much gauze as 
possible being carried up into the lower uterine segment. To be of any 
service the tamponade should be thorough. A little ether may be necessar)\ 
This is infinitely better than leaving the task half done. 

The vaginal Csesarean section has often been done in these cases, but 
is in my experience quite unnecessar)^, increasing rather than diminishing 
the risk, and often leaving the patient more or less disabled. (See p. 559. ) 

But suppose the patient is in the eighth or ninth month of pregnancy 
and the cervix is still hard and tmdilatable? The placenta lies across the 
cervix and the bleeding is free. The fetal heart-sounds are normal. Such 
cases are extremely rare. They do, however, undoubtedly occur. ]\Iany 
obstetricians have not seen one. 

In a case of this kind the abdominal Csesarean section constitutes the 
best method of treatment. The safety of the child is almost certain, and 
under modern methods the maternal mortality is probably less than it 
would be under a resort to forced delivery, or to the tampon and a waiting 
policy. The reader, however, need not fear that this choice will often be 
forced upon him. Alany of the operations hitherto reported have been 
performed by enthusiastic surgeons with little obstetrical knowledge. In 
one case the operator gave as a justification the fact that the os was 
no larger than a half dollar. 

The beginner is likely to show some timidity and hesitation when 
first meeting w^th this much-dreaded complication. Let us suppose the 
case to be one of the usual type, with a dilatable cervix that will admit 
one or two fingers. The hemorrhage is quite appreciable. The physician is 
alone, and is without special experience in obstetric technic: 

The first thing to do is to rupture the membranes. 

If the bleeding is not arrested turn promptly by the bipolar method 
and bring a knee to the vulva. 

Deliver slowly. Never drag the foetus forcibly through the cervix. 

Do not make any unnecessary examinations or allow anyone else to 
do so. A single examination has caused fatal hemorrhage. 

Remember that all manipulations are in immediate proximity to the 



PUERPERAL HE:M0RRHAGES 



483 



placental site and do not forget to wear rubber gloves and to observe strict 
asepsis. 

Guard unremittingly against hemorrhage, not only during, but after 

delivery. 

Premature Separation of the Normally Implanted Placenta 
(Accidental Hemorrhage) 

In this condition the placenta occupies its normal position near the 
fundus, but for some reason 
becomes separated from its 
attachment. The resulting 
hemorrhage is called acci- 
dental, in contradistinction 
to the unavoidable hemor- 
rhage which occurs when 
the placenta is implanted in 
the lower uterine zone (Fig. 
286 V 

Frequency. — Accidental 
hemorrhage is. fortunately, 
a comparatively rare phe- 
nomenon. Lobenstine and 
Harrar have noted its occur- 
rence forty-seven times in 
the course of 42,000 cases at 
the Xew York Lying-in 
Hospital. Yet Holmes, of 
Chicago, claims that, owing 
to lack of proper recording, 
too low an estimate has been 
given. He concludes that 
there is about one case of 
accidental hemorrhage in 
200 labors. This is based 
upon a report of 200 cases. 

Etiology. — Many causes 
have been assigned. ^lost 
of them are problematical. 

VV nen so many causes are Fig. 286. — Diagram representing a total separation of normally 
^iven it is evident that DOsi- implanted placenta. (After Pinard and Varnier, modified.) 

tive information is lacking. In a general way they may be divided into 
two classes : 

1. Traumatic, or those which come from without. 

2. Pathologic, or those which come from within. 

That traumatism may result in separation of the placenta is a priori 




484 PATHOLOGY OF PREGNANCY AND LABOR 

probable, and is shown by experience. I myself have seen the connection 
so closely that I cannot doubt it. Among the traumatic causes that have 
been observed or suggested are blows, falls, straining efforts, coughing, 
vomiting, unskilled manipulations in external version, etc. It is probable 
that in many cases a predisposition exists in the form of some one of the 
pathologic causes already mentioned. 

Of the pathological or internal causes we know little. It has been 
shown, however, that, as in placenta praevia, the majority of the patients 
art multiparse. This lends color to the assumption that endometritis in 
one form or another is the real cause. The coincidence of nephritis has 
often been noticed, and also that of syphilis and the acute exanthemata. 
Premature separation of the placenta is sometimes associated with fibroids. 
Profound mental shock has been adduced as a cause. 

Separation of the placenta during labor may be caused by the retraction 
of the uterus after the birth of a first twin, by the traction exerted by a 
short cord, or by unskilful manipulations in forceps operation or version. 

Mechanism. — It has been noticed in those cases in which the cause 
is plain, e.g., in those cases which follow a blow or fall, that symptoms do 
not appear immediately, but are often delayed for a day or two. This I 
have myself observed. It has been surmised that in these cases a separation, 
at first slight, is increased by the contractions of pregnancy, and that the 
resulting eft'usion of blood increases the area of separation. 

The bleeding may, or may not, be apparent to the eye. In the latter 
case the condition is called concealed hemorrhage. The mechanism of 
the two conditions is shown in Fig. 286. The blood may be con- 
fined between the placental and the uterine wall, causing the former 
to bulge inward toward the uterine cavity and the latter to bulge in the 
opposite direction. Sometimes this bulging can be felt through the abdom- 
inal wall. The pressure of the efi^used blood may rupture the amniotic 
sac, the blood escaping into the uterine cavity, or the blood may dissect its 
way downward between the membranes, which remain unruptured, and 
the uterine wall, whence it usually escapes into the vagina, though its 
escape may even in this case be prevented by the attachment of the mem- 
branes to the uterine wall, or perhaps by the interposition of a head well 
down in the pelvis. 

Cases are on record in which a severe hemorrhage has torn the placenta 
completely from its moorings and the organ has fallen to the cervix, there 
to be mistaken for a placenta praevia. Few men, however, have been 
privileged to see such a phenomenon as this. 

There are few cases in which the placenta or membranes are so firmly 
attached to the uterine wall that the blood cannot find its way eventually 
to the outside world. Therefore concealed hemorrhage, as it is called, 
is much more rare than the external form. Concealed hemorrhage is 
almost always followed sooner or later by the appearance of blood exter- 
nally. This occurred in all of DeLee's cases. 



PUERPERAL HEMORRHAGES 485 

Symptoms. — The symptom of the concealed form is severe locahzed 
pain near the fundus uteri. This is due to the separation of the placenta 
from the uterine wall. As Herman has pointed out, the uterus will tolerate 
a great deal of gradual stretching, as in hydramnion and twin pregnancy, 
but will not tolerate sudden stretching. Owing to the increased tension, 
the uterus becomes round rather than oval and acquires a sort of wooden 
hardness which is very characteristic, the uterus de hois of the French 
writers, ^^'ith these symptoms there develop rapidly the evidences of 
acute anaemia, the pallor, the faintness, dizziness and thirst, and the small 
and rapid pulse and other signs which we have already studied. At first 
there is no blood to be seen, later, perhaps, a little bloody serum, squeezed 
from the retained clots by the uterine contractions. These symptoms, 
occurring during the latter months of pregnancy, can have but one meaning. 

The diagnosis of the external form presents no difficulty. If hemor- 
rhage occurs during labor, and examination shows that the placenta cannot 
be reached, this fact, together with the other symptoms already mentioned, 
is quite sufficient. 

Even though the hemorrhage appears during the latter months of 
pregnancy, and before the cervix will admit the finger, there should be 
no trouble in diagnosing a well-marked case. The localized pain and the 
physical signs already mentioned are highly characteristic. A history of 
recent traumatism, or of some one of the predisposing causes, is very 
significant. Furthermore, there is no thickening or bogginess in the vaginal 
vault, and the presenting part can be easily palpated both externally and 
through the vaginal vault. 

Treatment. — There are many cases in which the hemorrhage is slight. 
After some overexertion there is a trifling hemorrhage, accompanied, per- 
haps, by certain ill-defined nervous symptoms of refiex origin. In these 
cases a few days' rest in bed is all that is necessary. The patient should 
be kept under observation, however, and cautioned against any undue 
exertion during the remainder of her pregnancy. 

But suppose that the hemorrhage is severe ? The first thing to do is 
to rupture the membranes. The propriety of this has been disputed upon 
theoretical grounds, but experience has shown its efficacy. A tight bandage 
is now applied and thirty drops of the fluidextract of ergot given every 
four hours. 

The further treatment depends upon the condition of the cervix and 
the period of pregnancy. Should the cervix be dilated (which is not 
usually the case), delivery is accomplished by version or forceps, according 
to indications. If the child is dead it should be promptly perforated. 

Probably the cervix is not dilated. What then ? If the foetus is prema- 
ture or small, it is better to wait, meanwhile keeping up the uterine com- 
pression and the ergot, and perhaps givins;- pituitrin as well. As Herman 
has well said, we are to judge the size of the foetus in these cases not so 
much by the menstrual history as by the height of the fundus. His rule 



486 PATHOLOGY OF PREGXAXCY AXD LABOR 

which I beheve to be a very good one, is to persevere with the above 
method of treatment in all cases in which the fundus does not extend 
higher than a point halfway between the umbilicus and the ensiform 
cartilage. 

Xow and then, fortunately not often, the case has gone on to term, the 
foetus is large, the cervix undilated, the symptoms grave. In such cases 
we are told to dilate the cervix manually or by the Bossi dilator and to 
deliver as rapidly as possible either by forceps or version. To this I can- 
not subscribe. Such an accouchement force is highly dangerous even to 
patients not already exsanguinated and shocked. 

For such a case the Ccesarean section, performed lege artis under ether 
oxygen anaesthesia, constitutes the quickest and safest way out of the 
difficulty. If the requisites for this are not at hand, the best that can be 
done is to dilate the cervix manually up to the point of admitting one or 
two fingers, rupture the membranes, insert a de Ribes bag, and use com- 
pression and ergot as already described. L^se pituitrin to stimulate 
contractions. Perforate if the child is dead. 



CHAPTER XXIII 
CONTRACTED PELVIS 

Pelvic Coxtractiox and Deformity 

Historical Note. — Previous to the eighteenth century but Httle of value 
■was known or, at any rate, pubHshed, about pelvic contraction as an 
obstacle to labor. 

A'an Deventer, in 1701, was the first to approach the subject from a 
comprehensive and scientific stand-point. 

Smellie in England, and Baudelocque in Erance, writing about the 
middle of the eighteenth century, made important contributions. Smellie 
demonstrated very clearly the n:echanism of labor in contracted pelves. 
His illustrations of the passage of the fetal head through the pelvic brim 
and of its conformation and moulding leave nothing to be desired even 
at this day. 

Baudelocque busied himself especially with pelvimetry. It was he who 
first demonstrated the diameter which bears his name, the anteroposterior, 
or external conjugate, most important of the external measurements. 

^Michselis and Litzmann, professors at the University of Kiel, have done 
more than any others in modern times to establish the subject upon a 
scientific basis, and the classification of Litzmann, 1861, is still for practical 
purposes the best devised. 

]vIore recently Schauta, Breus and Kolisko, and others have studied 
the subject from an etiological and developmental stand-point and have 
made elaborate classifications, which, while interesting from the stand-point 
of pure science, are for practical purposes less valuable than that of 
Litzmann, which is based upon the diflerences in size and shape of pelvis. 

Definition. — Of course no two pelves are exactly alike. From this it 
has arisen that there has been some discussion as to what really con- 
stitutes pelvic contraction. The question is still further complicated by the 
fact that, after all, pelvic contraction is a relative term. When the fetal 
head is large, the pelvis is relatively contracted though it be of average 
size, and when the head is small a moderate pelvic contraction may ofTer no 
obstacle at all to the progress of labor. Erom a clinical stand-point a pelvis 
is contracted when one or more of its diameters is so reduced as materially 
to modify the mechanism of labor, but this is a variable quantity. If we 
must be more definite, perhaps we may say that a reduction of 2 cm. in 
one of its diameters, or of i cm. in two diameters, constitutes pelvic 
contraction. According to Litzmann, a pelvis is contracted if one of its 
principal diameters is i^^ to 2 cm. below the normal. 

Frequency. — If we adopt the above figures as a criterion, we must 
conclude that about 15 per cent, of all pelves are contracted. According to 

487 



488 PATHOLOGY OF PREGNANCY AND LABOR 

Bumm, pelvic contraction sufficient in amount to cause serious trouble 
occurs in from 3 to 5 per cent, of all cases ; but pelvic contraction is far 
more common upon the continent of Europe than in England, Ireland, or 
the L^nited States. 

AMlliams estimates that from 20 to 33^^ per cent, of negro patients and 
7 to 8 per cent, of white women in this country have contracted pelves ; 
his conclusions, however, with regard to white women, were based upon 
statistics drawn from the clinics of Boston, St. Louis and Baltimore, and 
necessarily include a large number of foreign-born women, and, in my 
opinion, do not represent the facts as far as they apply to country practice 
in the United States or to private practice in our cities. In these classes 
of cases I think that 5 per cent, would be nearer the facts. 

I have no doubt that many cases of pelvic contraction are overlooked 
or diagnosed too late, now and then with serious results. 

Etiology. — To undertake a detailed study of the many, and not always 
well defined, causes of pelvic deformity would carry us far beyond the 
limits of this work. Nor is it necessary ; for what concerns the practical 
accoucheur is not so much the etiology of pelvic anomalies as their diag- 
nosis and treatment. Nevertheless, it is impossible to practise obstetrics 
intelligently, or even to take a satisfactory history of a given case, without 
some general knowledge of the subject and a clear appreciation of the 
principles involved. 

Wq will refer to the etiology of the different varieties of pelvic con- 
traction as we take up each one. In a general way we may say that most 
of the causes are antenatal ; either the patient inherits some constitutional 
disease or has been the victim of some failure in development, or some 
intra-uterine accident. Among the constitutional diseases inherited are 
rhachitis, the most common of all causes, osteomalacia, which many now 
hold to be a severe form of rhachitis and tuberculosis, or that mysterious 
thing known as the tubercular diathesis, a fruitful source of bone and joint 
disease. Among the congenital causes are chondrodystrophia or fetal 
rhachitis, assimilation of vertebrae, congenital dislocations, club feet, intra- 
uterine amputations by amniotic bands, etc. 

Among postnatal causes are general diseases resulting in local deformi- 
ties, e.g., acute anterior poliomyelitis ; local affections, e.g., vertebral, pelvic, 
hip- or knee-joint caries or injury, osteomyelitis, fractures, dislocations 
and abnormal growths, e.g., osteosarcoma, exostoses, etc. 

In order that the pelvis may develop normally the superincumbent 
pressure (vertebral pressure), and the pressure from below (femoral 
pressure), must be normal. It is easy to see how the carrying of heavy 
weights, or the misdirected pressure of a deformed spinal column, may 
result in deformity, how unilateral lameness by confining the femoral pres- 
sure to one side may produce an asymmetrical pelvis and how, in a young 
child, long confinement to bed from any cause may, by eliminating femoral 
pressure altogether, interfere with normal development. 



CONTRACTED PELVIS 489 

It is quite unnecessary to review here the anatomy of the normal pelvis. 
If the reader has forgotten it let him review his anatomy. It is requisite, 
however, to recall certain points in the development of the pelvis, and in 
the difference between the male and female pelvis, if we would study the 
subject intelligently, because in certain types of deformity the pelvis retains 
its fetal character, while in others it approximates the masculine type. 

In the new-born the sacrum and coccyx make with the vertebral column 
what is approximately a straight line. The promontory is much higher, 
the transverse diameter is smaller, and the lumbosacral portion is much 
less convex, not encroaching upon the pelvic cavity, while the pelvic inclina- 
tion is from seventy-five to eighty degrees as compared with from fifty-five 
to sixty degrees in the adult female. The sacrum, instead of being con- 
cave transversely, as in the adult, is transversely flat and relatively small. 
The whole pelvis is smaller a,nd approximates the funnel shape. The iliac 
tuberosities are nearer each other than the ischial spines, the reverse of 
what obtains in the adult. The iliac bones are much smaller and form, 
with the ileopectineal line, an angle of one hundred and fifty-five degrees 
as opposed to an angle of one hundred and twenty-five degrees in the adult 
female. 

According to Schaefi'er the dift'erence between the male and the female 
pelvis can be recognized as early as the fifth month of intra-uterine life. 
In the female the pubic arch is much wider, while the pelvis, as a whole, 
is m.ore shallow. Its transverse diameter is relatively greater and it is 
much more capacious at the outlet. The alse of the sacrum are much 
broader. The divergence begins at the fourth or fifth month of intra- 
uterine life, but continues long after birth ; in fact, until puberty. Why 
these intra-uterine differences in the shape of the pelvis ? Why does this 
sexual differentiation continue after birth and until puberty although the 
conditions as regards standing, sitting, walking, and the mechanical factors, 
vertebral pressure, femoral pressure, etc., remain the same? These are 
among the riddles of organic life about which it is interesting to speculate, 
but which as yet defy solution. Fortunately, their solution is not necessary 
to the solving of the practical problems which present themselves in con- 
nection with diagnosis and treatment. 

On the other hand, it is easy to understand that many postnatal causes 
may modify the shape and dimensions of the pelvis. What these causes 
are, and how they act, we shall see in connection with the etiology of the 
condition. 

The fetal pelvis is to be regarded as representing an arrest of develop- 
ment. There may have been a history of rhachitis, but this is by no means 
always the case. There are causes of arrested development other than 
rhachitis. The fetal characteristics already mentioned persisted through 
adult life. The transverse diameter is diminished and the promontory 
remains high. The sacrum is small and flat and situated farther back than 
usual. The pubic arch is small. All diameters are diminished. The brim 



490 PATHOLOGY OF PREGNANCY AND LABOR 

is round rather than oval. The sacrum and coccyx taken together form a 
Hne that is approximately straight and almost vertical. The tuberosities 
of the ischia are nearer each other than are the spines. 

The virile or masculine pelvis approximates the masculine t}pe. In a 
general way it resembles the fetal pelvis except that it is larger and heavier. 
The sacrum is small, the promontory high, and the pubic arch narrow. 
There is moderate contraction at the outlet. 

Classification. — Various attempts have been made to classify the 
different kinds of pelvic contraction upon an etiological basis. Such a 
classification, however, while interesting from the stand-point of pure 
science, does not serve the interests of the practitioner who wishes to cull 
in as short a time as possible the essential facts from a mass of confusing 
detail and limitless minutiae. It lays as much stress on rare forms of 
contraction, which the practitioner, or even the obstetrical specialist, 
seldom or never sees, as it does on the few varieties with which he will 
be sure to come in contact sooner or later, and pays as much attention to 
developmental anomalies and embryological curiosities as to the practical 
details of size, shape and measurement which are the ever)^-day care of 
the physician. At the bedside he has to deal, not with disputed questions 
in etiology and pathology, but with the mechanical difficulties to be 
overcome. 

To take a single example : Rhachitis causes a common form of pelvic 
deformity but may result in various kinds of pelvic contractions quite 
different from each other as regards treatment. Moreover, leading 
authorities in this field, as Tarnier and Budin, Breus and Kolisko, Schauta, 
and others, dO' not agree as to the etiological factors and therefore do not 
agree as to classification. 

Certain writers have divided anomalies into those which aff'ect the 
brim, cavity or outlet. To this it may be reasonably objected that in some 
forms of contraction all these divisions are affected, e.g., in a justo rninor 
pelvis, brim, cavity and outlet are alike contracted. I believe that Bumm 
is right in clinging to the older classification, and I think that that of 
Litzmann, published in 1861, has for practical purposes not been excelled, 
if indeed it has been equalled since that time. 

Schauta's Classification. — This classification, as modified by Hirst, 
is here appended as one of the best examples of the more elaborate classifi- 
cations. It makes a good framework for the study of pelvic deformity 
upon an etiological basis, and will be found of service to those who have 
time and opportunity for an exhaustive study of the subject. The student 
is advised to use the table for reference and as a guide to further study. 

Anojnalies of the Pelvis the Result of Faulty Development 
Simple flat pelvis. 

Generally equally contracted pelvis (justo minor). 
Generally contracted flat pelvis (non-rhachitic). 



CONTRACTED PELVIS 



491 




Fig. 287. — I, normal; 2, generally contracted; 3, flat; 4, generally contracted flat; 5, transversely 
contracted; 6, obliquely contracted; 7, osteomalacic. 



492 PATHOLOGY OF PREGNANCY AND LABOR 

Narrow funnel-shaped, fetal, or undeveloped pelvis. 
Imperfect development of one sacral ala (Naegele pelvis). 
Imperfect development of both sacral alae (Roberts pelvis). 
Generally equally enlarged pelvis (justo major). 
Split pelvis. 
Assimilation pelvis. 

Anomalies Due to Disease of the Pelvic Bones 
Rhachitis ; osteomalacia ; new growths ; fractures ; atrophy, caries, and 
necrosis. 

Anomalies in the Conjunctions of the Pelvic Bones 
Abnormally firm union (synostosis), which is found in elderly primi- 
parae, particularly at the sacrococcygeal joint and in the joints betw^een the 
coccygeal bones : 

Synostosis of the symphysis. 

Synostosis of one or both sacro-iliac synchondroses. 
Synostosis of the sacrum with the coccyx. 
Abnormally loose union or separation of the joints : 
Relaxation and rupture. 
Luxation of the coccyx. 

Anomalies Due to Disease of the Superimposed Skeleton 
Spondylolisthesis ; kyphosis ; scoliosis ; kyphoscoliosis ; lordosis. 

Anomalies Due to Disease of the Subjacent Skeleton 
Coxalgia; luxation of one femur; luxation of both femora; unilateral 
or bilateral club-foot; absence or bowing of one or both lower extremities. 

For the basis of clinical study, however, a classification like the follow- 
ing, which I have based upon that of Litzmann, and which deals principally 
with the more common forms, taking them up in the order of their 
frequency, and dealing with them from the point of view of size and 
shape ; in other words, regarding them for the time being simply as 
possible or actual obstacles to the progress of labor. 

Common Forms. — Flat pelvis: Simple; rhachitic ; generally contracted 
pelvis ; the flat and generally contracted pelvis ; outlet contractions, includ- 
ing funnel-shaped pelvis. 

Rarer Forms. — Oblique contractions ; transverse contractions ; spondy- 
lolisthesis ; split pelvis ; osteomalacia ; pseudo-osteomalacia ; irregular 
forms. 



FLATTENING (ANTEROPOSTERIOR SHORTENING) OF THE PELVIS (fIG. 2\ 

Flattening or anteroposterior shortening of the pelvis is the most com- 
mon form of serious deformity and will therefore be first considered. 
There are two varieties, the simple or non-rhachitic and the rhachitic. The 



CONTRACTED PEL\TS 



493 



former is tlie most common, at all events in our own country. Some 
^vriters, it is true, believe that true non-rhachitic flat pelvis is a rarity, 
the form ordinarily so called being usually the result of a mild or incipient 
rhachitis. One often meets, how- 
ever, with cases of flat pelvis in which 
there is no history of rhachitis and, 
moreover, this form of pelvis has 
been found in the new-born. 

But we need not stop here to 
speculate as to the part played by 
rhachitis in the production of pelvic 
flattening. \Miat principally con- 
cerns us at this point is that the 
mechanism of labor and the treat- 
ment, operative or otherwise, is the 
same in both varieties. They, there- 
fore, are best considered together. 

The Simple Flat Pelvis 

This form has little to distinguish 
it from the normal pelvis, except the 
anteroposterior shortening, and this 
shortening is rarely less than nine 
centimetres, the transverse diameter 
remaining normal. x\ll the diameters 
of the brim are shortened since it is 
the sacrum as a whole which ap- 
proaches the anterior pelvic wall, and 
not simply the promontory as the 
typical rhachitic pelvis. The general 
shape and curvature of the sacrum 
remain unaltered. This form of 
contraction is often overlooked by 
the careless observer, since the pa- 
tient is of normal height and appear- 
ance. There is nothing to arouse 
suspicion until the external con- 
jugate, or perhaps internal examination, shows that the sacral promontory 
is within reach. 

Etiology. — Some of these cases are congenital, others are attributed 
to overwork, especially the carrying of heavy weights in early life. The 
part played by rhachitis is as yet undecided. 




Fig. 288. 



-Myxoedema. Well-marked goitre. 
Flat pelvis. 



494 



PATHOLOGY OF PREGXAXCY AND LABOR 



The Rhachitic Flat Pelvis 
In this form of contraction the sacrum is not only pushed forward, but 
is also rotated forward on its transverse axis. Both these factors serve 
to shorten materially the anteroposterior diameter of the pelvis. The 
base or promontory of the sacrum is carried far forward while the rest 
of the bone points backward. The concavity of the sacrum, both longi- 
tudinal and lateral, is markedly diminished, the normally concave surface 
becoming almost flat. The tip is frequently bent upon itself. Xot infre- 
quently the first sacral vertebra projects downward as usual, the backward 

displacement not beginning 
Avith the first but with the sec- 
ond sacral vertebra. It is thus 
that the false promontory is 
formed. Sometimes this so- 
called false promontory is in 
fact the real promontory, the 
vertebra above not being the 
first sacral but the last dorsal, 
which has become assimilated to 
the sacrum. 

The jutting forward of the 
base of the sacrum causes such 
traction upon the sacro-iliac 
ligaments that the posterior- 
superior spines are made to ap- 
proach each other behind the 
sacrum. This, of course, tends 
to separate the ilia in front and 
thus the spines are drawn out- 
ward and backward so that the 
distance between them is equal 
to or greater than that between 
the crests, an important diag- 




FlG. 2i 



-Rhachitic pelvis, median section. Contrac- 



tion at the brim only. Xote forward projection of the nOStic sis'U obtaiucd iu COUrSC of 
sacral promontorv. " ^ - . • 

external pelvic mensuration. 
The pelvis, as a whole, is more shallow than in the non-rhachitic form, 
which is likely to deceive the inexperienced examiner and lead him to 
believe that forceps delivery will be easy, when in fact it may be difficult 
or impossible. The projecting promontory causes the brim to be heart- 
shaped. The bones are lighter and more fragile, as is usually, though not 
always, the case in rhachitis. 

The scope of this work does not permit a study of the pathology of 
rhachitis. It is well to note, however, that the disease, while much less 
frequent in this country than upon the continent of Europe, is more 



CONTRACTED PELVIS 



497 



contracted pelvis. It must be borne in mind, however, that the justo minor 
pelvis is not necessarily confined to very small women. It is occasionally 
found, when least expected, in women of average or even more than 
average stature. 

But the generally contracted pelvis is not always perfectly symmetrical, 



Fig. 294. 



Fig. 29s. 





Fig. 



Fig. 294. — True dwarf unusually small. 
295. — Dwarf with thyroid atrophy. Generally contracted pelvis. 



nor is it always proportional to the size of the patient. It is occasionally 
found in women of average or even more than average size, a fact which 
should make us realize the necessity of testing the adaptability of the head 
to the pelvis in all cases during the latter weeks of pregnancy 
32 



Again it 



498 



PATHOLOGY UF PREGXAXCY AND LABOR 



may be complicated by evidences of rhachitis, or it may approximate the 
infantile or the masculine type. In all these cases the condition is a real 
deformity. In the category of generally contracted pelves fall also the 

various types of dwarf pelvis, which need 
not be considered in detail here. It should 
be noted, however, that every dwarf does not 
of necessity have a small pelvis. The typical 
dwarf pelvis is simply an ordinary' pelvis in 
miniature. The so-called chondrodystrophic 
dwarf is a dwarf only by virtue of having 
A'ery short legs, and the pelvic diameters 
may be quite sufficient. Here again we see 
the necessity of pelvic examination. Exter- 
nal appearances are vers' suggestive, but they 
are by no means infallible. A woman whose 
figure is to all appearances perfectly nor- 
mal may have marked pelvic contraction. 
while a dwarf may have a normal labor. Of 
course such cases are exceptional, but the 
lesson they teach is plain. 

There are several varieties of the dwarf 
pelvis. In the first there is the rhachitic 
dwarf which is simply the rhachitic pelvis in 
miniature. 

The cretin d^varf pelvis, which is a minia- 
ture of the generally contracted pelvis, with 
the imperfect bony development character- 
istic of cretins. 

The hypoplastic dwarf pelvis, a minia- 
ture of the normal pelvis. 

The so-called pelvis nana, or true dwarf 
pelvis, a miniature of the infantile pelvis, 
-« ^-- --"" already referred to, except for the lack of 

ossification of the epiphyseal cartilages 

Fig. 296.— Chondrodystrophic d^-arf. (^IgS. 294, 295 and 296). 




THE FLAT AND GENERALLY COXTRACTED PELVIS 

This form combines the characteristics of both forms. It is usuallv, 
though not always, of rhachitic origin. All the diameters are reduced but 
the reduction is most marked in the anteroposterior diameter. It is espe- 
cially in this class of pelvis that the extreme deformities, the classical tvpes 
of absolute contraction, are found. Schaeffer holds it to be a transition from 
occupying a place between the rhachitic flat pelvis and the pseudo- 
osteomalacic pelvis (Figs. 297 and 298). 



COXTRACTED TELMS 



499 



The three forms of contraction mentioned above are held by most 
Avriters to be the most freqnent of ah, ahhongh these writers do not agree 
among- themseh'es as to which of the three should be accorded the place 

Fig. 298. 



29: 




Fig. 297.- 
FiG. 298. 



-Rhachitis. Right genu valgum. 
-Rhachitis; double genu valgum. 



Flat and generally contracted pelvis. 
Pelvis flat and generally contracted. 



of honor in this respect. Most of the German writers believe that the 
simple flat pelvis is the most common of the three. Ahlfeld and Bumm 
dissent emphatically from this opinion, believing that many cases classified 
as simple flat pelvis are really of rhachitic origin. Tarnier and Budin are 
of the same opinion. It seems to me, that the opinion of the latter authori- 



500 PATHOLOGY OF PREGNANCY AND LABOR 

ties is confirmed by the fact that in America where rhachitis is compara- 
tively rare flat pelvis is also rare, or at all events much less frequent than 
the generally contracted. 

It is quite probable that the relative frequency with which these types 
are met varies with the locality. There is no doubt whatever that the 
generally contracted pelvis is much more common in our own country than 
is either type of flat pelvis. This statement refers to women of the 
white race. Among negroes rhachitis is far more common. 

It is true that moderate contraction at the outlet, without other apparent 
abnormalities, is very common. Williams, indeed, claims that 44 per cent, 
of all cases of pelvic contraction come under the head of outlet contractions, 
or funnel pelves, as he calls them. This may be true theoretically, but in 
practice in most of these cases the deformity is slight, involving at the 
worst a delayed second stage or perhaps a forceps operation and a perineal 
tear. To classify them all, however, as examples of pelvic deformity gives 
the student a wrong perspective. There is no doubt, however, that the 
subject of outlet contraction has not received the attention which it 
deserves. 

OUTLET CONTRACTION (fUNNEL PELVIS ) 

When the pelvic canal converges from above downward instead of 
from below upward, as is normally the case, the pelvis is said to be funnel- 
shaped. As we go on we shall see that in certain unusual cases, e.g., in 
kyphosis and in asymmetrical pelvis, this funnel shape is very constant and 
that in cases of general contraction a narrowing of the outlet out of pro- 
portion to the other diameters is often found. Williams has recently called 
attention to the fact that the outlet contraction is often found in cases 
where all other pelvic measurements are normal. He believes that this is 
due not to a persistence of the masculine or infantile type, as has been 
generally supposed, but to the assimilation of the last dorsal vertebra to the 
sacrum. This brings us to the subject of assimilation. However this may 
be, it is the merit of \\^illiams to have shown that slight or moderate 
contraction at the outlet is the most common form of pelvic contraction 
observed among the white women of this country. Alarked degrees of 
outlet contraction, it is true, are rare, but sufficient diminution in the 
capacity of the pelvic outlet to render the second stage long and difficult, 
to necessitate diflictilt forceps delivery, or to make bad tears of the peri- 
neum inevitable is quite common. These cases have been overlooked in the 
past, because so many men have been content with taking the external 
measurements, and perhaps the Internal conjugate, and have paid no 
attention to the outlet diameters (Figs. 299 and 300). 

THE PELVIS OF ASSIMILATION 

This is an anomaly of development, a lumbar being fused with a 
sacral vertebra, or vice versa. Fusion of the last lumbar and first sacral 



CONTRACTED PELVIS 



501 



vcrtebrcT. the so-called " high assmiilation," results in a pelvis approximat- 
ing the male type. The sacrum now has six vertebrae and, of course, the 

Fig. 299 




Fig. 299. — Kyphosis. Contraction of pelvic outlet. 
Fig. 300. — Dorsolumbar kyphosis. Outlet contraction. 

promontory is high. Sometimes it cannot be reached, at other times there 
is a double promontory. The brim is round rather than oval, the cavity 
deep and funnel-shaped, but — and this should not be forgotten — there is 



502 PATHOLOGY OF PREGNANCY AND LABOR 

sometimes a moderate transverse contraction at the brim. Thus we see 
that high assimilation may be a cause of delay, both at brim and at outlet. 
Whenever the head remains persistently above the brim and the delay can- 
not be otherwise accounted for one should think of high assimilation. 

In some cases the upper, or first sacral, vertebra may coalesce with 
the first lumbar spine, making the sacrum shorter. This is called low 
.assimilation. It is of no special clinical importance. 

In some cases assimilation may be the cause of oblique contraction, one 
side of the vertebra resembling a lumbar and the other a sacral vertebra. 

The assimilation pelvis may give trouble either at brim or outlet. 
'\A"'hile ^"\llliams calls special attention to outlet contraction, it is my 
opinion that it is the cause of many unexplained cases of trouble at the 
brim, especially since external measurements are approximately normal and 
promontor}^ hard to reach. 

Oblique Deformities 

Although often classified as among the rarer deformities, oblique con- 
tractions of the pelvis are, in my opinion, more common than is usually 
supposed. 

Rhachitis of the severe type is rare among native American women, but 
hip- and knee-joint diseases are by no means uncommon. In some cases 
the external measurements are normal and the pelvis apparently symmetri- 
cal, but internal examination discloses asymmetry. 

I recall a hospital case in which the patient was permitted to go on 
for a long time in labor because her external measurements were normal 
and her internal conjugate sufficient. An internal examination disclosed 
a pelvic asymmetry and a history of severe traumatism and probable 
fracture of the pelvis. 

These cases are especially apt to be overlooked, if a careful history 
is not taken. In every case in which there is a history of hip or knee 
trouble in childhood, or of operation upon, or injury to, the hip or knee or 
any part of the pelvis or lower extremity, of spinal scoliosis, infantile 
paralysis or prolonged recumbency from any cause, careful palpation of 
the lateral pelvic walls and measurements of the pelvic outlet should not 
be neglected. Sometimes deformity is only found on internal examination. 

OBLIQUE COXTEL\CTIOX OF THE PELVIS 

From the rather disproportionate amount of attention that is often 
given to the Xaegele pelvis, and the fact that it is often designated as the 
Xaegele, or obliquely contracted, pelvis one might suppose that other 
varieties of oblique contraction are rare. This is by no means the case. 

Oblique contraction oi the pelvis may be due to many causes and 
with these the reader should become familiar. The most common is one- 
sided pressure upon the pelvis. This pressure may be from above (verte- 
bral pressure), or from below (femoral pressure). As an example of the 



CONTRACTED PELVIS 



503 



former we have lateral curvature of the spine. Examples of the latter 
are numerous, e.g., hip- or knee-joint disease, or unilateral lameness from 
anv cause. Other causes are dislocation, congenital or acquired, fractures, 
with shortening of the limb, amputations, etc. The coexistence of 
rhachitis, of course, makes the deformity more marked. Now and then 
presence of an exostosis or of a mass of callus from an old fracture dimin- 
ishes the available space in one side of the pelvis. We have already men- 
tioned assimilation as a cause of oblique deformity. It may be difficult 
or impossible to make the diagnosis during the life of the patient. 

THE COXALGIC PELVIS 

This form is the most common of all (Fig. 301) and is due to unilateral 
femoral pressure. Of course, the name " coxalgic " is not strictly correct, 




Fig. 301. — Contraction at the outlet. Coxalgic pelvis. 

since femoral pressure may be due to many causes other than hip disease. 
The essential point is that the pressure is upon the sound side, and there- 
fore the contraction is upon that side. There is, in these cases, a moderate 
lateral curvature of the spine, which, like the contraction, is usually upon 
the sound side. 

There are some exceptions to this rule, however. When there is 
atrophy of the affected limb, as in congenital dislocation of the hip-joint, 



504 PATHOLOGY OF PREGXAXCY AND LABOR 

there may also be atrophy of the pelvis upon the affected side, in which case 
the contraction may be upon the same side. 

THE XAEGELE PELVIS (OBLIQUELY COX- 
TRACTED, AXKYLOSED PELVIS ) 

This is a very rare form of pelvic 
contraction. One of the sacral alai is 
rudimentar}^, and there is an ankylosis 
of the sacro-iliac joint of the same 
side. This renders the pelvis smaller 
on the aflected side, at the same time 
pushes the symphysis in the opposite 
direction. The result of this is an 
obliquely contracted pelvis, the con- 
traction being upon the affected side. 
The sacrum is twisted a little on its 
long axis, so that its concavity looks 
toward the affected side, and there is 
some moderate lateral cur\^ature of the 
lumbar spine, this also looking toward 
the affected side. 

TRAXSVERSE COXTRACTIOX 

Transverse contraction of the pelvis 
(Fig. 302) without other abnormality 
is not common. Of course, every justo 
minor pelvis is contracted in the trans- 
verse as well as in all the other 
diameters, and we have seen that mod- 
erate transverse shortening is char- 
acteristic of various kinds of pelvic 
anomaly. AA'ell - marked transverse 
contraction, however, in a pelvis other- 
wise normal is rare. 

THE ROBERTS TRAXSVERSELY COX- 
TR ACTED PELVIS 

A'ery rare, indeed, is the Roberts 
pelvis, the most marked example of 
transverse contraction. It is charac- 
terized by a lack of development of the 
Ae'iDru:^.^ sacral al^ on both sides, together with 

ankylosis of the sacro-iliac joints. It is essentially a bilateral Xaegele 
pelvis. The reader need have little fear of encountering this anomaly, since 
only ten cases are recorded in the entire literature of pelvic contraction. 




Fig. 302. — Transverse contraction at 



CONTRACTED PELMS 505 

THE KYPHOTIC PELVIS 

The kyphotic, or nunipLack, pelvis is usually the result of tubercular 
caries of the spine, though in rare cases it is due to rhachitis. When the 
kyphosis involves only the dorsal vertebrae, the pelvis is but little affected, 
but when it is in the dorsolumbar position there is a compensating lordosis 
of the lumbar spine, which tends to carry the promontory of the sacrum 
backward and its tip forward. At the same time, and as a coeffect, the 
lateral walls of the pelvis converge and the ilia flare outward, enlarging 
the false pelvis, though there is moderate contraction at the brim. Owing 
to the tilting backward of the sacrum the conjugate diameter is lengthened. 
The result of these changes is a pelvis with plenty of room at the brim, 
but with its capacity diminishing in the excavation and becoming narrowest 
at the outlet ; in other words, a funnel-shaped pelvis. In some cases the 
outlet contraction is so great as to constitute an insuperable obstacle to 
delivery, except by pubiotomy or the Caesarean section. This, however, 
is not usually the case, and I believe that there is danger of some unneces- 
sary operating in these cases. To perform the Caesarean section or 
pubiotomy simply because the patient has a marked kyphosis is altogether 
unjustifiable. I recall a patient who was sent to the Misericordia Hospital 
for Caesarean section, but whom I delivered easily with the forceps. Her 
second labor was a precipitate one. In many cases a moderate perineal 
tear is the only disability involved. 

In certain rare cases the lordosis is so extreme as to block the pelvic 
inlet. Fehling called this the pelvis ohtecta, which means the '' roofed-in " 
pelvis. 

SCOLIOTIC PELVIS 

Spinal scoHosis is an occasional cause of oblique deformity of the 
pelvis. It is usually rhachitic in origin. As in kyphosis the deformity 
must be in the dorsolumbar region in order to affect the pelvic measure- 
ments. In rhachitic scoliosis the sacrum is rotated and pushed to one side 
and there are corresponding changes in one lateral half of the pelvis. 
Owing to the coexisting rhachitis there is no outlet contraction in these 
cases. The contraction is at the brim. 

Combinations of kyphosis and scoliosis, and of either, or both, with 
rhachitis may occur. Thus we may have the kyphoscoliotic, the kypho- 
rhachitic pelvis, etc. It is obvious that to consider all possible combinations 
would carry us too far. 

SPONDYLOLISTHESIS 

This is a rare form of contraction due to an exaggerated lordosis of the 
lumbar spine. The last lumbar vertebra slides downward and forward 
until it comes to occupy a position in front of the sacrum instead of above 
it, osseous union taking place. By the forward dislocation of this vertebra 



506 PATHOLOGY OF PREGXAXCY AND LABOR 

the vertebrae above it are dragged downward. Two, three, or even four, 
vertebrae may descend, with the result that the pelvis is almost completely 
blocked. So great, indeed, is the deformity in some cases that one can 
feel the bifurcation of the aorta through the vagina. The sacrum is dis- 
placed downward and backward and rotated upon its transverse axis. 
There is a compensatory action upon the symphysis which is brought 
to a higher plane than usual. Pelvic inclination disappears, the plane of 
the brim becoming practically horizontal. The pelvis assumes the funnel 
shape of the kyphotic pelvis. 

According to Xeugebauer the condition is due to imperfect develop- 
ment of the interarticular portion of the last lumbar vertebra. Cases 
have been observed in which it was due to fracture of the vertebra. Of 
course, if ossification does not occur, w^e have cartilage instead of bone 
and the anterior part of the vertebra may slide forward and downward. 
Carrying of heavy weights has been adduced as a cause. Arbuthnot Lane 
cites the case of the coal heavers. 

The appearance of the patient is characteristic. The descent of the 
lumbar spine causes the thorax to drop, as it were, into the pelvis, and the 
lower ribs are almost on a line with the pelvic brim. The patient has a 
peculiar waddling gait. 

OSTEOMALACIA (mOLLITIES OSSEUM) 

This disease is almost unknown in England, France, and America, but 
endemic in central and southern Europe, and recently in Japan. It is 
attended by pain and tenderness affecting the bones and especially those 
of the vertebral column and pelvis, confining the patient to bed during 
pregnancy and resulting in various and often extreme deformities, and 
followed by decrease in stature, ^^^ith termination of pregnancy the symp- 
toms disappear. The bones are softened and easily bent. Indeed, the 
condition is sometimes called compressed pelvis. The microscope shows 
the characteristic changes of osteitis and osteomyelitis. The softened 
bones yield easily to pressure and sometimes take on fantastic shapes. 
Pressure from above (vertebral pressure) pushes the promontory down- 
ward and forward, while pressure from below (femoral pressure) drives 
the lateral walls of the pelvis toward each other, giving to the pelvic brim 
the classical ''beak shape " of osteomalacic pelvis. 

The etiology is not definitely settled. As in rhachitis, poor hygienic 
surroundings constitute a predisposing cause. Fehling regards it as a 
trophoneurosis due to certain changes in the ovaries not well understood. 
Certain Italian writers believe the disease to be of bacterial origin, but 
this theory has not received a ready acceptance. 

No other disease presents the same symptoms as this, especially the 
shortness of stature. In the early stages it may be necessary to wait for 
a time, however, before making a positive diagnosis. 



CONTRACTED PELMS 



507 



THE PSEUDO-OSTEOMALACIC PELVIS (COMPRESSED PELVIS ) 

Pseudo-osteomalacia is the name sometimes applied to an extreme 
form of rhachitis in which the bones become very soft and are easily 
compressed into the form assumed in cases of osteomalacia, described 
on p. 506,, including the beak-shaped symphysis. The promontory 
is pressed downward and forward. It differs from rhachitis, however, in 
the fact that while the gross appearances 
are much the same as in true osteo- 
malacia it differs from the latter condi- 
tion, which is an inflammatory process 
occurring in the adult, and in which lime 
salts are not replaced by cartilage, as in 
rhachitic children, but what remains is 
decalcified fibrous tissue. 

There are certain irregular and 
atypical deformities of the pelvis which 
defy classification from the clinical 
stand-point. Among these are the vari- 
ous varieties of tumor that may originate 
in bone or cartilage. Enchondromata 
are the most common, but osteomata, 
csteosarcomata, and others, are occa- 
sionally met with. Then we may have 
pelves deformed as the result of frac- 
ture. Such cases are necessarily rare, 
in the first place because fractures of the 
pelvis are rare, and in the second place 
because they are ordinarily the result of 
great violence and therefore often fatal. 
They do occasionally occur. Now and 
then it is not the fracture per se that 
causes the difficulty, but the callus that 
is thrown out during the process of 
healing. 

It remains to mention for the sake of 
completeness two obstetric curiosities, 
the split pelvis and the pelvis spinosa, 
though the reader, even though he be an 
obstetric specialist, will probably never ^^^• 
see a case of either. 

The pelvis spinosa is characterized by the presence upon its inner 
surface of small, sharp, bony projections which have been known to injure 
the uterus during labor and which it would seem might also injure the 
child, although they are not usually large enough to constitute an obstruc- 
tion to the progress of labor. 




303. 



-Fracture of the pelvis, 
of the excavation. 



Narrowing 



508 PATHOLOGY OF PREGNANCY AND LABOR 

The split pelvis is a developmental anomaly and is usually associated 
with exstrophy of the bladder. The pubic bones are completely separated 
from each other, or united only by a fibrous partition. Less than ten cases 
are on record. 

Litzmann has reported a case of absence of the sacrum and one of 
delivery after operative removal of the sacrum. It is also well to remem- 
ber cases due to accident (Fig. 303). 

JUSTO MAJOR PELVIS 

A pelvis is said to be justo major when all its diameters are larger than 
usual, but the pelvis as a whole is symmetrical. This can hardly be called 
an abnormality. It is said to be a cause of precipitate labor, but I do not 
believe this to be the case. In the absence of pelvic contraction or unusual 
size of the head, delay in labor is due for the most part not to the pelvis, 
but to the soft parts. For example, in the case of a primipara the head 
has normally descended into the cavity of the pelvis long before the 
beginning of labor and it is the condition of the pelvic floor that determines 
the rate of progress. Similarly, in the case of a primipara, the head 
usually descends to the floor of the pelvis as soon as the cervix is fully 
dilated. 

History. — If the practitioner would avail himself of every diagnostic 
aid, he should review carefully the life history of every case. Inquiry 
should be made as to evidences of rhachitis in infancy, e.g., late dentition, 
late walking, delayed closure of fontanelles, sleeplessness, bottle-feeding, 
etc. A history of infantile paralysis, of hip-joint disease, of " white 
sw^elling " of the knee, of resection of the knee-joint, or of any condition 
that might cause unilateral lameness, is always highly significant. History 
of long confinement to bed before the age of twelve, for any reason 
whatever, is very suggestive. 

Most important of all, in doubtful cases, is the history of previous 
labors, if any, including the size of the children and their condition at 
birth, whether still-born, deeply asphyxiated, or normal, and the character 
of delivery, whether natural or operative. The character of previous 
operations, the difficulties with which they were attended, where and by 
whom they were performed, and their results, should be matters of 
investigation. 

The nationality of the patient should not be overlooked. Rhachitis, 
for example, is much more common in women of continental Europe and 
in the negro race. Osteomalacia is almost unknown in America. 

Inspection. — The attention of even the casual observer is at once 
arrested by unusual shortness of stature, marked spinal curvature, a limp- 
ing or one-sided gait, hemiplegia, operative scars about the hip- or knee- 
joints, or now and then by the scar of a former Csesarean section or 
pubiotomy. This happened in one of my cases, the patient denying any 
knowledge of the character of the operation from which the scar resulted. 



CONTRACTED PELVIS 509 

Then, too, there are often the classical evidences of rhachitis, the peculiar 
shape of the head, irregular teeth, projecting lower jaw (prognathism), 
curvature of the bones of the extremities, " knock knees," " pigeon breast," 
enlargement of the costal cartilages (the rhachitic rosary), and the square- 
shaped fingers of the rhachitic hand. Anomalies of the Raute of Michcelis, 
described below, are also highly suggestive. According to Fabre the aver- 
age height of women is 1.6 m. and this is rarely attained in cases of pelvic 
contraction, especially of the rhachitic type. Let us not, however, over- 
look the cases which do occasionally occur in taller women. 

When we come to the inspection of the abdomen there is much that 
speaks plainly: most noticeable is undue prominence of the abdominal 
tumor. In the primipara this takes the form of a pointed abdomen, the 
SpitdmiicJi of the Germans. Quite otherwise in multiparse. The lax 
abdominal wall of the woman who has borne many children can no longer 
support the enlarged and heavy uterus which hangs forward over the 
symphysis, sometimes indeed so far that the fundus is lower than the 
cervix. This condition is known as pendulous abdomen, Hangehauch of 
the Germans, ventre pendant of the French. 

Of course both varieties of abdominal distention are usually due to the 
fact that the fetal head cannot enter the brim and the entire foetus must 
remain in the abdominal cavity. An added factor, as we shall see later, 
is to be found in the fact that in certain varieties space is diminished. 
Hence, even when, as in outlet contraction, the head has descended into the 
pelvic cavity, the intra-abdominal space is still insufficient. 

In cases of well-marked contraction at the brim the outline of the head 
above the symphysis may be plainly seen, as well as felt, through the 
abdominal wall, resembling very much a distended bladder. 

Whenever in the case of a primipara the head remains above the brim 
during the latter weeks of pregnancy and cannot be made to descend by 
external pressure, one should think of pelvic contraction. This is a very 
suspicious sign, and sometimes indicates pelvic deformity which cannot 
easily be made out by vaginal examination, e.g., the so-called '' high 
assimilation," of which we shall say more presently. 

On the other hand, in outlet contractions the head may be far down 
in the cavity of the pelvis, and again in certain forms of rhachitic pelvis 
the pelvis as a whole is so shallow that the head appears to be relatively 
much lower than is really the case. 

THE RAUTE OF MICH.ELIS 

Among the evidences furnished by inspection the Raute of Michcelis 
is one of the most significant. It can be better illustrated than described. 
The four depressions or dimples, shown in Fig. 304, can, except in the 
case of very stout women, be made out without trouble. A corresponds 
to the depression below the spine of the last lumbar vertebra, B and C to 



510 



PATHOLOGY OF PREGXAXCY AXD LABOR 



the posterior-superior spines of the iHum, and D to the upper end of the 
interghiteal fold. \Mien this figure is of average size and shape, a normal 
pelvis is probable, though of course not certain. A^ariations in its size 
and shape are, however, highly significant. If, for example, the lateral 
depressions are far apart, one thinks of a large sacrum and an ample pelvis. 
If they are close together it is probable that the pelvis is of the infantile 
or of the masculine type. If the upper depression is nearly in line with the 
lateral depressions this indicates that the sacrum has been pushed down- 
ward and forward, as in rhachitic flat pelvis and in certain cases of spinal 
curvature, ^"\^hen the figure is irregular, e.g., when one lateral depression 




Fig. 304. — The Raute of Michcdis. 

is on a lower level than the other and nearer the median line, we are at once 
reminded of an oblique contraction. The student will do well to study the 
Raute, first in normal cases and later in every abnormal case which he 
may be so fortunate as to meet. 



Pelvimetry 

A'aluable as are the evidences of history and inspection, we possess 
a more exact method in the actual measurement of the pelvic diameters. 
There are two kinds of pelvimetry, external and internal. External pel- 
vimetry is that part of pelvimetry that can be done under the guidance of 
the eye, and consists in measuring certain diameters. 



CONTRACTED PELVIS 



511 



1. The interspinal diameter, or distance between the anterosuperior 
spines of the ilia, 26 centimetres (Fig. 305). 

2. The intercristal diameter, or the distance between the crests of the 
iha. 2() centimetres. 




Fig. 305. — Measuring the distance between the ihac spines. 

3. The intertrochanteric diameter, or the distance between the tro- 
chanters, 32 centimetres (Fig. 306). 

4. The external conjugate diameter, or diameter of Baudelocque, 21 
centimetres (Fig. 307). 



512 



PATHOLOGY OF PREGXAXCY AXD LABOR 



5. The right and left obHque diameters, taken from the right posterior- 
superior spine of the ihuni to the anterior-superior spine of the iHum on 
the left, and vice versa, 22 centimetres. 




Fig. 306. — Pleasuring the distance between the trochanters. 

6. The intertuberal, or transverse, diameter of the outlet, 11 centi- 
metres. 

How are these measurements to be taken and what do they respectively 
indicate ? They are to be taken with the pelvimeter. Its construction and 



COXTRACTED PELA7S 



513 



the method of ttse are sufficiently indicated in the accompanying illustra- 
tions. Type forms are the pelvimeters of Baudelocque and CoUyer. The 
latter is more convenient for the practitioner, since it can be carried in 











Fig. 307. — Measuring the external conjugate. 

the pocket or the obstetrical bag. Test every pelvimeter zvith a tape 
measure or a foot rule. Not all pelvimeters are accurate. 

The interspinal and intercristal diameters indicate approximately the 
transverse diameter of the pelvis and the inclination of the ilia. As 

d>3 



514 PATHOLOGY OF PREGNANCY AND LABOR 

explained elsewhere, if these diameters are equal, or if the interspinal is 
the larger of the two, a rhachitic pelvis is to be suspected. Shortening of 
an oblique diameter is found in hip- joint disease and similar conditions. 
^Marked diminution of the intertrochanteric diameter indicates transverse 
narrowing. jMost important of all external measurements is the external 
conjugate diameter, or the diameter of Baudelocque, indicating as it does 
with approximate accuracy the anteroposterior diameter of the pelvic 
brim. The intertuberal diameter, by which is meant the distance between 
the tuberosities of the ischia, should not be forgotten, or we will occasion- 
ally overlook a case of outlet contraction. 

In taking the above measurements the points of the pelvimeter should 
be placed squarely upon the external surface of the ilium. It is only in 
this way that a solid and uniform base for measuring can be found. The 
spines of the ilia can always be easily made out, and these having been 
located the crests, which are less definite, are made out by sliding the arms 
of the pelvimeter backward and forward along the borders of the al?e 
until the points of greatest separation are determined. 

In taking the external conjugate one tip of the pelvimeter is placed on 
the anterior upper surface of the symphysis, exactly in the median line, 
while the other is placed in the centre of the depression, just below the 
prominent spine of the last lumbar vertebra, which can usually be felt 
without difficulty. If this landmark is not available, as may be the case 
in fat women, a very close estimate may be made by locating a point two 
and one-half centimetres above a line midway between the two lateral 
depressions below\ 

Baudelocque, who was the first to appreciate its importance, believed 
that it bore a very definite relation to the true conjugate, but this has 
been shown to be incorrect. A^'arious factors, especially the height and 
thickness of the sacrum and the thickness of the symphysis, operate to 
prevent exactness. 

Nevertheless this diameter is an important one, since experience has 
shown that when it is less than 17 to 18 centimetres anteroposterior 
contraction is usually present. 

The right oblique diameter is taken from the right posterior-superior 
spinous process of the ilium to the left anterior. The patient lies upon 
her right side. All this is reversed in taking the left oblique. In either 
case the physician stands behind the patient. 

THE DIAMETERS OF THE OUTLET 

These are as follows : 

The anteroposterior diameter, taken from the middle of the pubic 
arch to the tip of the sacrum. 12^ centimetres (Fig. 308). 

The transverse or intertuberal diameter, 10 centimetres (Fig. 309). 

The posterior-sagittal diameter taken from the middle of the inter- 
tuberal line to the tip of the sacrum. This diameter needs only to be 



CONTRACTED PELMS 



515 



taken when there is distinct shortening of the intertuberal. Its significance 
will be considered in connection with treatment of outlet contraction. 

The anteroposterior diameter is easily measured with the ordinary 
pelvimeter. The intertuberal diameter may be taken with Williams's 
pelvimeter or by the method of Klien. If the soft parts are pushed back 
by the hand of an assistant, the distance between the tuberosities may be 
directly taken with the tape measure, as I have often demonstrated, without 
the aid of any instrument at all. 

Of course not all these measurements are necessary in every case. In 
the case of a multipara who has had easy labors they are not necessary, 




Fig. 308. — Taking the anteroposterior diameter of the pelvic outlet. 

and in the case of a primipara, if the head is well down in the cavity of the 
pelvis, it is only necessary to estimate the size of the outlet. Again, in 
estimating the size of the outlet, if the distance between the tuberosities 
is ample, the other outlet measurements are not necessary. 

If, however, the patient is a primipara and the head still remains above 
the brim, or if the patient has a history of difficult labor, or if the examiner 
is in doubt, the examination should be thorough. 

Value of These Measurements. — Of these measurements I believe 
those of the external and internal conjugates to be the most valuable, 
and that of the internal conjugate to be the most valuable of all. The 
experienced obstetrician learns, after a time, that he can estimate the 



516 



PATHOLOGY OF PREGNANCY AND LABOR 



capacity of the pelvis better with the hand than with any pelvimeter, and 
that internal exploration often enables him to dispense with external 
measurements. It will never do, however, to begin in this way. The 
practice of pelvimetry by the student and young practitioner is indis- 
pensable if he would safeguard his future patients. The young prac- 
titioner, too, will do well if he takes and records the ordinary measurements 
in every case and compares the results. I would repeat, for the sake of 
emphasis, that he should never omit the transverse diameter of the outlet. 




Fig. 309. — Taking the transverse diameter of the outlet. 

The measurement of the intertuberal diameter may be made during any 
vaginal examination, entails no pain or even inconvenience upon the patient, 
and occasionally gives highly A^aluable information. 

Finally, he should never regard the measurement of the normal pelvis 
as a waste of time. For the beginner, especially, is this of great value. 
He who knows well the normal pelvis will not fail to recognize the 
abnormal. 

The examiner should bear in mind the fact that we cannot rely upon 
external appearances. Here, as elsewhere, the practice of obstetrics is 
full of surprises. Now and then marked spinal or other deformity, 



CONTRACTED PELVIS 



517 



apparent to the eye of all, may be accompanied by a pelvis ample in size, 
while what appears to be the perfection of form may go with some pelvic 
anomaly capable of causing the most severe dystocia. 

Internal Pelvimetry 

AMiile external pelvimetry affords valuable information it is, except in 
extreme cases not often met with in general practice, suggestive rather 
than positive. It is by internal pelvimetry that we seek to attain more 



u 




WW, 



Fig. 310.— Taking the diagonal conjugate. Pelvis flat. Elbow not depressed. 



definite information. Here, as so often in obstetrics, the best of all instru- 
ments is the hand. \^arious pelvimeters have been devised for internal 
use, but none of them are satisfactory. The experienced accoucheur needs 
no such instrument, while the beginner could get little information from 
its use. The latter should utilize from the start every opportunity of 
examining the pelvis ; first the normal pelvis, and then the abnormal. 
Let him not imagine that time spent in examining normal pelves is wasted. 
Here again one who knows well the normal pelvis is not likely to fail to 
recognize the abnormal, and he who finds difficulty with his hand will 
hardly succeed with some complicated instrument. 

The most important of t-he internal measurements is the anteroposterior 



518 



PATHOLOGY OF PREGNANCY AND LABOR 



diameter of the pelvic brim, also known as the internal conjugate diameter, 
or simply as the internal conjugate. The diameter is taken, or would be 
taken, if possible, from the tip of the sacrum to the middle of the top of 
the symphysis, and measures about eleven centimetres. After delivery the 
promontory of the sacrum can be plainly felt through the lax abdominal 
wall, and the conjugate directly measured. During pregnancy this is, of 
course, impossible and we are obliged to resort to an indirect method 
which, however, gives results that are approximately correct and are often 
of the greatest value. 

In taking the internal conjugate, the patient should be in the dorsal 
position with thighs moderately flexed and hips drawn well over the edge 

of the bed or table, preferably the 
latter. The elbow of the operator 
is held low so that the fingers are 
carried almost directlv upward. 
The third and fourth fingers are 
folded upon the palm, and the per- 
ineum sloAvly and steadily pushed 
up by the fold between the second 
and third fingers. The radial mar- 
gin of the hand is kept in close 
contact with the ligamentum arcua- 
tum and the promontory is reached 
by the tip of the second finger. The 
common error of the beginner is to 
mistake some part of the concavity 
of the sacrum for the promontory. 
This is avoided by letting the finger 
follow the concavity of the sacrum 
upward, until it slips over the 
promontory. Sometimes there is 
a false promontory below the true 
one. Here it is best to follow the 
practical suggestion of Bumm : measure the distance from both and make 
the shortest measurement the basis of our estimate of the prognosis. If 
the patient is a primipara, or if she is very sensitive, a few whiffs of ether 
may be necessary. 

^^'hen the operator is satisfied that his finger is in contact with the 
promontory, and that the radial border of the hand is in contact with the 
ligamentum arcuatum, he locates the point at which his hand touches the 
ligament, using the index finger-nail of the other hand for this purpose, 
and then withdraws both hands without changing their relative positions 
(Figs. 310, 311, 312 and 313). The distance is then measured. This 
distance is of course not the real conjugate, since it is taken from the 
bottom, not the top. of the symphysis. It is called the diagonal conjugate. 




Fig. 311. — Further illustration of the method of 
taking the diagonal conjugate. Note that the pelvis 
is of the male type. Conjugate ample. Elbow 
depressed. 



COXTRACTED PELVIS 



519 



It is, as the reader will see at once, the hypothenuse of a triangle whose 
base is the length of the symphysis and whose perpendicular is the dis- 
tance which we are seeking to determine — the true conjugate or distance 
from the top of the symphysis to the sacral promontory. Strictly speaking, 
the obstetric conjugate is a little below the top of the symphysis, i.e., at 
the point nearest the promontory. The distance from the very top of the 
symphysis is sometimes called the anatomical conjugate. It is obvious 
that the diagonal conjugate is longer than the true conjugate, and that, 
in order to estimate the latter, a deduction must be made. Now if the 
conditions were the same in every case, the deduction would be the same 
and the estimate of the true conjugate would be an easy matter. Unfor- 
tunately this is not the case. The symphysis may be very short and the 
hypothenuse but little longer than the perpendicular, or it may be unusually 




Fig. 312. — Distance measured by assistant. 

long, in which case the difference between the hypothenuse and the per- 
pendicular is very marked. In the first instance the deduction would be 
less than usual, in the second it would be greater. 

Then, too, conditions will vary with the inclination of the symphysis 
and the height of the promontory. The higher the promontory the greater 
the deduction. If the symphysis is flat, making a very acute angle with the 
conjugate, the deduction will be less. If, on the other hand, it approaches 
the perpendicular the deduction will be greater. Under normal conditions 
the deduction Avill average about one and one-half centimetres. 

Thus it appears that our methods of determining the length of the true 
conjugate are not very exact. Still, they are of great practical value. In 
some cases their positive is greater than their negative value, e.g., if one 
can feel the promontory easily, let us say with one finger, he is certain that 
marked contraction exists, but, on the other hand, a promontory high and 



520 



PATHOLOGY OF PREGNANCY AND LABOR 



difficult to reach may project so far as to make natural delivery difficult 
or impossible. This is a characteristic of the pelvis of assimilation. 

Prognosis. — It is sometimes said that the prognosis in pelvic con- 
traction is directly proportionate to the degree of contraction. This is a 
great mistake. Paradoxical as it may seem, the prognosis is best in cases 
of marked contraction : i.e., of course, under correct treatment. AMien this 
contraction is made out in advance there is but one treatment, Csesarean 
section at term. AA'ith this treatment properly carried out the fetal 



M 




X 



/ 




Fig. 313. — Taking the diagonal conjugate, continued. Distance measured by assistant. 

mortality is practically nil and the maternal mortality perhaps two per cent. 
In the cases of border-line contraction, however, the indications are not 
so clear and with the best intentions and in the most competent hands 
the fetal mortality will be much larger, while the maternal mortality will 
be quite as large. Furthermore the maternal morbidity, and the number 
of cases in which the mother is injured more or less seriously, are very 
much greater. So far as the labor itself is concerned, the most important 
element is the character of the uterine contractions. This is especially 
manifest in the second stage. Powerful contractions at this time are the 
most important aids, and if the head is fairly compressible, sometimes 



COXTRACTED PELVIS 521 

effect delivery in spite of really serious obstruction. On the other hand, 
weak and irregular contractions render the prospect of spontaneous 
deliver}' almost hopeless. 

Effect of Pelvic Coxtractiox Upon the Clinical Course of 

Pregnancy 

Pelvic contraction does not make its influence felt during the early 
months of pregnancy. The only exception to this rule is that a projecting 
promontory may cause retroflexion of the gravid uterus. During the 
later months sym.ptoms of pressure may be manifested, as distention and 
dyspnoea. Dyspnoea and gastric symptoms are the result of upward pres- 
sure, while the pressure of the head against the pelvic brim may cause 
oedema and congestion of the lower extremities, and markedly increase 
the tendency to varicosities of the vulva and lower extremities. Now and 
then this pressure upon ner^'es that cross the brim of the pelvis causes 
severe pain at the point of pressure or along the course of the sciatic nerve. 
The weight and pressure of a pendulous abdomen, or more rarely the 
lateral pressure of a highly mobile uterus, may cause discomfort and 
require an appropriate binder. 

How Pelvic Contraction Affects the Mechanism of Labor 

Even in normal labor the head is a close fit for the pelvis. It is obvious, 
then, that if the pelvic diameters are measurably diminished and the pelvic 
canal is to be transversed by the head there must be a corresponding 
difference in the mechanism by which this is accomplished. And this we 
find to be the case. 

The difference can be briefly and clearly stated. It is not difficult 
to understand and should be mastered by the reader if he would be able to 
follow intelligently the course of labor in these cases. 

As we have already noted, the first stage in cases of pelvic contraction 
is divided into tw^o periods or sub-stages, the period of configuration and 
the period of expulsion. Before the head can advance it must be con- 
figured, that is, it must be adapted in size and shape to the canal through 
which it must pass. How is this accomplished ? In normal labor the head 
is configured, or moulded, as it advances. Not only do the soft bones of 
the head change in shape, but the bone which is in advance, usually the 
anterior parietal, is pushed under its fellow and both under the occipital, 
and thus is the head materially reduced in size. 

Let us first consider the mechanism in flat pelvis. Here the small 
anteroposterior diameter of the pelvic brim prevents the head from entering 
directly, i.e.^ with the sagittal suture midway between the promontorv and 
the symphysis. The result of this is a parietal presentation usually anterior, 
occasionally posterior. Let us consider first the former. The anterior 
parietal bone is found at the brim, a larger or smaller segment entering 



522 PATHOLOGY OF PREGXA^XY AXD LABOR ' 

the upper part of the pelvic cavity. The sagittal suture is felt far back, 
near the sacrum and running transversely across the pelvis. Only a small 
segment of the posterior parietal bone can be felt, perhaps none at all. 
The anterior parietal bone becomes fixed at the symphysis and the head 
under the influence of the uterine contractions gradually becomes molded 
sufficiently to pass the pelvic brim. The posterior parietal bone is pressed 
against the sacrum, it is flattened and pushed under the anterior parietal 
bone. During the process of engagement the larger occipital end of the 
head becomes accommodated to that side of the pelvis toward which it 
points, i.e., to the larger side of the pelvis, thus substituting the shorter 
bitemporal diameter for the longer biparietal diameter where there is least 
room. After the greater circumference of the head has passed the brim, 
the occiput rotates to the front, and as there is usually in these flat pelves 
plenty of room at the outlet, the subsequent mechanism does not differ 
from that which obtains in normal delivery. If the examining finger notes 
that the sagittal suture is approaching the median line and an increasing 
segment of the posterior parietal bone can be palpated, the attendant may 
be sure that the patient is making satisfactory progress. 

Less commonly, according to Litzmann in 25 per cent, of flat pelves, 
the posterior parietal presents. This presentation is less favorable. Lat- 
eral flexion is more marked, the head being bent sharply and crowded 
directly against the symphysis. Delivery may be diflicult or impossible 
(Fig. 314). 

Mechanism in the Generally Contracted Pelvis. — Here the head 
enters the brim in one of the oblique diameters and in a condition of 
extreme flexion, the small fontanelle sinking deeply so that it sometimes 
reaches even the middle of the pelvis, while the large fontanelle cannot 
be reached. This, it will be observ^ed, is simply an exaggeration of the 
process observed in normal labor, by which nature endeavors to substitute 
for the f ronto-occipital diameter the smaller suboccipito-bregmatic diame- 
ter. Extreme flexion in these cases is of good omen. Therefore, if the 
examining finger finds the head extended and both fontanelles easily 
palpable, the case is not progressing satisfactorily. On the other hand, if 
it notes marked flexion of the head, as shown by the descent of the small 
fontanelle and its approach to the median line, the outlook is favorable. 
In these cases, however, the difficulty is not always over with the passage 
of the head through the brim, since these pelves are usually contracted 
throughout ( Fig. 315). 

Mechanism in Generally Contracted and Flat Pelvis. — In this variety 
the mechanism Is a combination of the two varieties just described. There 
is the anterior parietal presentation of the flat pelvis combined with the 
extreme flexion that occurs In cases of general contraction. 

Mechanism in Outlet Contractions. — Here there Is usually no nar- 
rowing at the brim, and the head Is found well down in the cavity of the 
pelvis at the beginning of labor. This Is especially true In cases of kyphotic 



CONTRACTED PELMS 



523 



Fig. 314- 



Fig. 31; 





Fig. 3i6. 




Fig. 317. 




Pig. 314. — Mechanism in flat pelvis. Position L. O. T. Altitude intermediate. Anterior rotation 

one-fourth of a circle. 
Fig. 315. — Mechanism in generally contracted pelvis. _ Position L. O. A. Altitude of forced flexion. 

Anterior rotation one-eighth of a circle. 
Fig. 316. — Mechanism^ in flat and generally contracted pelvis, first method. Position L. O. T. 

Altitude forced flexion. Anterior rotation one-fourth of a circle. 

Fig. 317. — Mechanism in flat and generally contracted pelvis; second method. Position L. O. T. 

Altitude, I, intermediate; 2, forced flexion. Anterior rotation one-fourth of a circle. 

pelvis, since the intra-abdominal space is contracted. In the movement of 
extension the occiput, owing to the narrowness of the pubic arch, finds its 
point d'appni not at the subpubic arch, but some distance below it. Exten- 



524 PATHOLOGY OF PREGXAXCY AXD LABOR 




Fig. 318. — Transverse contraction at the outlet. 




1 



Fig. 319. — Irregular contraction at the outlet. 



COXTRACTED PELMS 525 

sion is thus rendered difficult or impossible, according to the length of the 
intertuberal diameter. There is usually no obstacle to rotation. 

Mechanism in Irregular Forms of Pelvic Contraction. — In oblique 
contraction of the pelvis nature often makes an effort at accommodation 
by directing the occiput into the less contracted half of the pelvis, and in 
various atypical deformities irregular forms of mechanism have been 
observed, which it would be a needless and an unprofitable task to attempt 
to follow or describe (Figs. 318 and 319). 

Effect of Pelvic CoxTrL\CTiON Upon the Clinical Course of Labor 

If the position and presentation are normal, the uterine contractions 
good, and the disproportion not too marked, labor may proceed with little 
deviation from the usual course, and delivery prove uneventful. If, 
however, the titerus does not contract well, or if the disproportion is 
marked, a characteristic train of symptoms ensues. 

In the first place, malpositions and malpresentations of all kinds are 
more frequent and so are the various difficulties that attend them, these 
difficulties being, of course, increased by the scanty space available. The 
reason for the frequent occurrence of complications is not far to seek. 
The head cannot descend into the pelvis, nor can it become engaged at the 
brim. Hence nature's processes of accommodation result in the substitu- 
tion of some other portion of the foetus, or, the head floating above the 
brim, one diameter is as likely to present as another. Since the head does 
not enter, or at all events does not fill, the brim, the amniotic fluid escapes 
in large quantities and overdistends the amniotic pouch. For the same 
reason prolapse of the cord and of small parts is much more frequent, 
according to Bumm five times as frequent as under ordinary circumstances. 
If the amniotic pouch does not rupture, it can often be felt hanging 
loosely in the pelvis like a glove finger, the head high above. This sign is 
highly characteristic and is found in no other condition. Sometimes, even 
if the cervix dilates, it closes again, since the head does not come down 
to maintain and complete the dilatation. 

But let us suppose that the head has become engaged and the cervix 
has at last been drawn up over the head and dilatation is nearly or quite 
complete. The second stage has now begun, but it differs markedly from 
the second stage of normal labor. Before the head can advance it must 
be configured or moulded to fit the brim of the pelvis, and this may require 
hours. How this moulding is accomplished we have already seen. When 
it is completed the pains become expulsive in character. Thus we have the 
second stage divided into two parts, the stage of configuration and the 
stage of expulsion. The moulding of the head and its passage through 
the superior strait constitute a tedious affair. When the head has become 
moulded so that its greatest diameter can pass the pelvic brim, the patient 
feels the impulse to bear down. This is an important diagnostic sign of 
progress. The pains, which during the stage of configuration are often of 



526 PATHOLOGY OF PREGXA^XY AND LABOR 

intolerable severity, become a little more bearable, since the patient feels 
that she is helping herself, and the bearing-down efforts produce a certain 
amount of physiological anaesthesia and the area of pressure is changed. 
After the head has entered the pelvic cavity, if the pelvis is flat, the course 
of labor does not differ materially from that which obtains in normal labor. 
If the pelvis is of the generally contracted variety, however, the second 
stage may be difficuh and prolonged. In funnel-shaped pelves the same 
thing occurs. In outlet contractions, e.g., in kyphosis, there is no trouble 
with the first stage of labor, and it is only the delay at the outlet that 
attracts attention to the shortened intertuberal diameter, if this has not 
already been noticed. 

IXFLUEXCE OF LabOR COMPLICATED BY PelVIC CONTRACTION UpOX THE 

]\Iaterxal Structures 

One would suppose that in labor under these circumstances there would 
be more injury to the soft parts of the mother than in normal labor, and 
this we find to be true. In severe cases the injuries may be of grave 
character. ]\Iost of them occur during the stage of configuration, when 
the head is stationar}^ for hours. The familiar congestion and swelling 
of the anterior cervical lip are exaggerated, and sometimes the whole 
cervical ring that is exposed to pressure may slough away and be expelled 
during labor. Sometimes the prolonged pressure may result in vesico- 
vaginal or other fistula. The interference with the return circulation in 
cases of generally contracted pelvis may cause swelling and congestion 
of the vaginal mucous membrane, and in bad cases even the vulva may be 
black and oedematous. The pelvic joints may be injured and difiiculties 
in locomotion result. Obstinate paralyses may result from pressure upon 
nerves that pass over the pelvic brim. Severe lacerations result from 
attempts at delivery. Pressure necrosis may result in severe or even fatal 
infection. 

Effect of Labor Complicated by Pelvic Contractiox Upon Fcetus 

As might be expected, the foetus shows evidence of the all-too- 
narrow passage. Sometimes the only reminder is moulding of the 
head. Except for the overlapping of the bones of the fetal skull this 
differs rather in degree than in kind from the moulding obsei*ved in 
ordinary labor. Hsematomata are common. The projecting promontor}^ 
often leaves its mark upon the head. " If the reader will recall the mechan- 
ism of labor in these cases, the following diagram, modified from Fabre, 
will be plain. In flat pelvis it is the parietal region, and usually the 
posterior one, that suffers. L^sually the injury is only skin deep — a super- 
ficial red line. Occasionally, however, there is a raw ulcerated surface 
which requires considerable time for healing. In the generally contracted 
pelvis the line is vertical, while in the generally contracted and flat pelvis 
the line takes the form of a curve. 



CONTRACTED PELVIS 527 

Far more serious are the cases in which the skull is actually fractured. 
This is usually caused by forcibly dragging the head through a contracted 
brim, either during version or in the course of a forceps operation. I 
have seen it occur as a result of forceps delivery in which extraction was 
elTected with the Tarnier instrument after failure with the Elliott forceps, 
but only at the expense of the fetal skull. When these fractures involve 
the top of the head they do not necessarily result badly. When near the 
base they are almost always fatal. If the evidences of cerebral pressure 
are marked the scalp should be incised and the offending fragment raised. 

Doubtless many cases presenting no permanent marks of gross injury 
suft'er later from the consequences of cerebral congestion and of minute 
hemorrhages. 

Asphyxia due to the causes which usually obtain in delayed labor, and 
which operate in still greater degree in these tedious and difficult cases, 
is very common. Other factors which tend to increase the danger to the 
foetus are premature rupture of the membranes and prolapse of the cord, 
both of which, as already seen, are very common in labor complicated by 
contracted pelvis, and all the dangers incident to difficult forceps opera- 
tions, versions and extractions of the after-coming head. 

Thus we see that the dangers to the foetus in slight and moderate 
contraction of the pelvis are many and great. Paradoxical as it may 
at first sight seem, they are far greater than in cases of marked deformity. 
The latter are usually treated by Csesarean section and the danger to the 
child is practically nil. 

Contracted Pelvis: Treatment. — The treatment of contracted pelvis 
constitutes one of the most complex and difficult problems in obstetrics. 
In spite of the attention that has recently been given to the subject and 
of the enormous literature that has accumulated, there is still much differ- 
ence of opinion even among men of large experience. 

^ly own views upon the matter differ radically from those which the 
reader will find in some well-known and excellent text-books. 

In the first place, I would earnestly warn the reader against the idea 
that every case of pelvic contraction needs active treatment. This mis- 
take is often made by those who approach the subject from the surgical 
side without an adequate obstetrical experience; and it is in this class 
of cases that many unnecessary pubiotomies and symphysiotomies have 
been performed. Alany cases of pelvic contraction require no treatment 
other than that adapted to normal labor. Every obstetrician of experience 
can recall cases in which the pelvic measurements were such as to lead 
him to expect serious trouble, but in which, contrary to all expectations, 
labor ran an uneventful course. 

It is customary to divide all cases of contraction into groups, according 
to the degree of contraction, and to consider these groups separately. The 
student, however, must not imagine that the lines separating these groups 
are arbitrary and well defined. Since our methods of estimating the 



528 PATHOLOGY OF PREGNANCY AND LABOR 

internal diameters of the pelvis are not exact, since we cannot estimate 
definitely the measurements of the fetal head, and since we can never 
know in advance what nature can accomplish in a given case, it is obvious 
that such rules will be subject to many exceptions and modifications. 

For these groups the length of the true conjugate is taken as a basis of 
classification, thus, according to Litzmann : 

Group A includes cases in which the external conjugate is less than 
5.5 cm., absolute contraction. 

Group B, those in which the true conjugate is between 5.5 and 7.3 cm., 
relative contraction. 

Group C, those in which the true conjugate is between 7.4 and 8.3 cm., 
moderate contraction. 

Group D, those in which the true conjugate is between 8.4 cm. and the 
normal; slight contraction. 

Some writers add 0.5 cm. to the conjugate diameter if the pelvis is of 
the generally contracted variety. I agree with Williams and others that 
this is not necessary. In my opinion it only serves to complicate a situation 
already replete with difficulties. Of course, marked shortening of the 
transverse diameter should be taken into account. But this is a rarity. 

Strangely enough, the most marked deformity is most easily treated. 
This is because there is but one thing that can be done in Group A with 
its tiny diameter of less than 5.5 cm. — only the Caesarean section will suffice. 
Not even craniotomy will permit the extraction of the foetus. If infection 
is present or probable the uterus should be removed. 

If the case is seen during pregnancy, the patient may ask the induction 
of abortion, and it has often been performed under these circumstances. 
In view of the comparative safety of the Caesarean section with modern 
technic such a course seems hardly justifiable. 

In group B the Caesarean section is still the operation of choice, since 
it is impossible within the limits of this group to extract a living child per 
z'ias naturales, and the operation is probably at least as dangerous as the 
Caesarean section. 

Hence we see that in the treatment of cases with a conjugate of 7^/^ 
centimetres, or less, the problem is usually an easy one. In the great 
majority of cases the Caesarean section is the only treatment to be con- 
sidered. True, there is in Group B the alternative of perforation, but it 
is probable that under modern conditions the extraction of a full-term 
child through conjugate of less than 7^ centimetres, and this by an inex- 
perienced operator, is quite as dangerous as the performance of the 
Caesarean section. 

However dramatic in detail and occasionally tragic in outcome these 
cases of extreme contraction may be, it is when we come to the cases of 
moderate contraction that we meet with the greatest difficulty. The charac- 
teristic feature of these cases is that one can never foretell the outcorne. 
Many of them will be delivered spontaneously, to the great surprise and 



CONTRACTED PELVIS 529 

relief of the attendant who had anticipated and prepared for some serious 
operation, or perhaps to the dismay of the hospital interne who had 
counted upon gaining valuable experience. In others a forceps operation 
may succeed. Occasionally a version may result happily. Again, a 
CcTsarean section may prove the only means of securing a living child. 

I cannot agree with those who decry the seriousness of even slight 
contraction (nine to ten centimetres). I have seen serious dystocia in 
these cases. This is especially likely to be observed when the foetus is 
of unusual size, and unfortunately it is difficult to be certain upon this point. 

If we could put every one of these cases into a hospital, and perform 
Csesarean section early in labor, results almost ideal could be obtained. 
Of course, this could not be done since it would involve the performance 
of many unnecessary operations, but there is an important practical lesson 
here. Every case of pelvic contraction should be treated in a hospital,' 
or at all events under conditions permitting the aseptic and reasonably 
skilful perfomiance of the Csesarean section, should this become necessary. 
Xo doubt these precautions would prove in many cases to have been 
lumeces&ary, but this would be far more than atoned for by the fact that 
both fetal and maternal mortality would be practically nil. 

But whether in hospital or without, justice demands that these cases 
shall be given the test of labor and in the meantime we cannot sit idly by! 
leaving our patient to get on as best she may, until approaching exhaustion 
is forced upon our attention, ^^^hat can we do for her in the meantime ? 

]^Iost important of all is the preservation of strict asepsis. The 
attendant must never forget for a moment that his patient may have to 
undergo an abdominal section, the danger of which is enormously increased 
by the presence of infection. Hence the progress of the case should be 
determined as far as possible by external methods. Vaginal examination 
should be strictly limited and rubber gloves invariably used. Once the 
necessity of abdominal section has been determined, such examination 
should be absolutely forbidden. The house surgeon, as well as the prac- 
titioner, confronted with a doubtful case, should remember that his respon- 
sibility is here very great. 

Next in importance is the preservation of the membranes. Their 
premature rupture not only delays or arrests progress, but enables bacteria 
to gain access to the uterine cavity, thus favoring infection. It is best 
avoided by the use of great care in examinations, by keeping the patient 
in bed in the lateral position during the first stage of labor, and by forbid- 
ding any straining or bearing-down efforts daring this stage. Some 
writers advise the introduction of a rubber bag or colpeurynteur to prevent 
rupture. To my mind the influence of such treatment in preventing 
rupture is doubtful, and the necessary manipulations increase the danger 
of infection. 

If at the end of two or three hours a careful examination shows that 
the head is still above the brim with no prospect of engagement, and con- 
34 



530 PATHOLOGY OF PREGNANCY AND LABOR ^ 

firms the fact that distinct pelvic narrowing exists, Csesarean section or 
pubiotomy should be performed. jNIy own results with the Csesarean 
section in these cases have been good, and I have come to believe that 
most of the cases will do well if they have been treated aseptically and 
attempts at delivery have not been made. These things I believe to be of 
more importance than the mere duration of labor. Personally I am 
strongly in favor of the Csesarean section as equally safe for the mother 
and far safer for the child. I believe that with the head floating above the 
brim it is impossible to be certain that the disproportion is not too great 
for the easy and successful extraction of the head after the division of the 
pubic bone. Such mistakes have been made and the consequences have 
been most disastrous. 

But suppose that the physician is alone and cannot procure assistance, 
or if for any reason the performance of an aseptic and reasonably skilful 
laparotomy or pubiotomy is plainly impossible, or if such an operation is 
positively forbidden, what is to be done? If the child is living and viable 
the choice lies between forceps and version. 

Technic of the Forceps Operation and of Version in Pelvic Contrac- 
tion. Choice Betv^^een the Two Operations. — In a certain sense both 
these operations are makeshifts in pelvic contraction. Not only is their 
performance a difficult task, but the fetal mortality is much increased, and 
unless they are done lege arfis they are by no means without danger to the 
mother. Nevertheless, there are cases in which they must be performed. 
The physician may find himself alone and may find himself obliged to 
operate under circumstances which render the Csesarean section impossible, 
or at least extremely hazardous. It will not do for writers and teachers to 
assume that circumstances are ideal. The practitioner is obliged to do 
what is best under existing circumstances. 

Much depends upon the technical skill of the operator and upon his 
experience in the field of pure obstetrics. This undoubted fact is not 
generally appreciated, and it is too often assumed that, while the Csesarean 
section can only be properly performed by the surgical or gynaecological 
specialist, it makes little difference who makes trial of the forceps or 
attempts the delivery of the after-coming head. This is a grave error, as 
every practical obstetrician knows. As a matter of fact, either one of 
these procedures carried out in a case of pelvic contraction is a far more 
difficult task than the Csesarean section, and can only be properly performed 
by one who has had special experience and training : another argument for 
placing all cases of pelvic contraction in a maternity hospital. 

Most writers upon the subject of pelvic contraction seem to assume 
that the technic of both version and the forceps operation is the same as in 
cases in which the pelvis is normal. There are, however, certain important 
modifications, with which every student and practitioner should be familiar, 
and which may be of assistance in these trying emergencies. 

There is also an erroneous, but widely diffused, idea that craniotomy 



CONTRACTED PELMS 531 

is an easy and ready way out of the difficulty in all forms of pelvic deform- 
ity : that it is an operation which anyone can perform even though he be 
quite incompetent to complete a simple laparotomy. When the conjugate 
is in the neighborhood of eight centimetres, the mutilation and extraction 
of a full-term child, especially if the child be large, which is often the case 
in these difficult labors, is a task which requires a high degree of obstetrical 
skill and which carries a distinct risk. 

If the head remains above the brim and cannot be made to engage by 
rupture of the membranes and external pressure the forceps operation is 
usually contra-indicated, though a careful operator may be allowed a brief 
trial. A^rsion, however, is usually to be preferred. This operation, it 
must be admitted, is something of a forlorn hope for the child, but still 
gives it a chance, while it furnishes quick relief for the mother and spares 
the operator the terrible alternative of craniotomy upon the living child. 
Much depends upon the experience of the attendant. One often sees men 
who, from lack of correct teaching, are unfamiliar with modern methods of 
forceps operating and use of an axis-traction instrument, but who have by 
virtue of necessity acquired considerable skill in performance of version. 

Often the physician finds it difficult to decide between the two opera- 
tions. The relative indications have been given elsewhere and need not be 
repeated here. It is the fashion to taboo the forceps in flat pelvis on the 
ground that the after-coming head enters the brim more easily, and to 
condemn version in contracted pelvis because the long occipito-frontal 
diameter becomes engaged in the shortened transverse diameter of the 
pelvis. There is without doubt a certain amount of truth in these con- 
tentions, but the practitioner must be guided by actual conditions rather 
than theoretical considerations. If, for example, in a case of flat pelvis the 
head can be brought down into the brim, as may happen if the head is of 
moderate size, it is obvious that the forceps should be preferred no matter 
what the rule may be. It is also plain that when some malpresentation, e.g., 
face or brow, coexists, version is the operation of choice or, indeed, of 
necessity. 

If the head becomes fixed at the brim, even though a large segment has 
not entered, the forceps operation is easier, though still a hazardous task. 

If the head becomes well engaged in the pelvic brim, the task becomes 
much simpler and the forceps operation is always to be given the prefer- 
ence. Even in this case, however, and for reasons not always easy to 
determine, perhaps unusual size or shape of the fetal head, or some 
obstruction in the excavation or at the outlet, progress is impossible. In 
this case the attendant should remember that version is sometimes easily 
accomplished when its accomplishment is least expected. This has been 
discussed in the chapter on version. 

The reader will see that the choice between the two operations is not 
always an easy one, but, if he will consider carefully the general principles 
involved, he need seldom go seriously astray. 



532 PATHOLOGY OF PREGNANCY AND LABOR 

One thing is plain. A cautious, skilful, and tentative resort to the 
forceps does no great harm and does not preclude the subsequent perform- 
ance of version or pubiotomy, while a version half completed leaves the 
operator in a most unenviable position and of necessity sacrifices the 

child. 

Technic of the Forceps Operation. — If the head is above the brim and 
cannot be made to engage by external pressure, this is ordinarily contra- 
indicated, though in good hands the operation is occasionally successful. 
When a fairly large segment has become fixed at the brim the prospects are 
better. 

If the head is high, it will be found to occupy one of two positions. In 
flat pelvis it is transverse and but little flexed, while in the generally 
contracted pelvis it is oblique and strongly flexed. Let us consider the 
first instance. 

As we have noted in the chapter on the forceps operation, the applica- 
tion of the forceps to the sides of the head above the brim is impracticable, 
even when the pelvis is normal. It is plain that in pelvic flattening the 
difficulty is much increased. The forceps, then, are applied obliquely. 
There is in these cases a marked tendency for the forceps to slip backward 
over the occiput. The French accoucheurs seek to avoid this by intention- 
ally directing the curve of the forceps toward the face. The modus 
operandi is made plain by the accompanying illustration from Jeannin 
(Fig. 320). 

The blades penetrate more deeply than is usually the case. Short and 
weak forceps are of little value in these cases. It may be necessary to 
carry the handles far backward against the perineum to secure locking. 

If the old model is used, tractions are at first made directly downward ; 
i.e., as nearly downward as they can be made by the use of Pa jot's 
manoeuvre. This can be materially aided by the use of tapes. The axis- 
traction model, however, is much to be preferred. With this the head 
takes the proper direction automatically. I have seen success with the 
Tarnier instrument after failure with the Elliott forceps in the hands of 
an unusually skilful operator. 

It is the experience of the French writers, who have carried the 
technic of the forceps operation to a very high degree of perfection, that 
Tarnier s older model, which is provided with a perineal curve, works best 
in these cases, securing a firmer and more secure grasp of the fetal head. 
This model is known to us in New York as " Lusk's modification," and is 
now seldom used here. It would seem, however, that it should at least be 
at hand in hospitals. 

The application of the forceps when the head is high and strongly 
flexed, as in general contraction, does not dififer from that in the ordinary 
high forceps operation except that it is more difficult. IMoreover, the 
difficulty does not necessarily decrease with the passage of the brim, since 
these pelves are often of the funnel type. 



CONTRACTED P^ELVIS 



533 



In outlet contractions, e.g., in kyphotic pelves, the head has usually 
rotated or nearly rotated and there is no difficulty in making a good applica- 
tion to the sides of the head. A forceps with a very moderate pelvic 
curve is to be preferred. The handles should not be raised too early, since 
during the hnal extension of the head the occiput is applied, not to the 
pubic arch, but to the intertuberal line. The method of delivery resembles 
that necessary in posterior positions of the occiput. Indeed, in outlet 



.^*^ 




Fig. 320. — Oblique application of forceps above the brim, head in L. O. T. position. 

contraction a posterior position is not a disadvantage and no effort should 
be made to correct it. It is difficult to bring the v^ide biparietal diameter 
through the narrow pubic arch. When difficulty is experienced in the 
extraction of the head moderate lateral movements ("pendulum move- 
ments ") of the forceps are very useful. 

The employment of the forceps in pelvic contraction has been severely 
censured. When this censure is directed against their unskilful use, and 



534 PATHOLOGY OF PREGNANCY AND LABOR 

in particular against persistent and senseless efforts to overcome obstacles 
by force, it is fully justified. The cautious and tentative use of the forceps 
in good hands as a means of diagnosis is quite a different matter. If a few 
tractions result in no advance or prospect of advance, and in particular if 
there is great difficulty in locking the instrument, it is wise to desist and 
to resort to some other method of delivery. 

Technic of Version in Pelvic Contraction. — In these cases version 
often proves \ery difficult. The necessary manipulations are hindered by 
lack of room. Sometimes both the intrapelvic and the intra-abdominal 
spaces are diminished. It may be difficult to reach a knee or a foot, and it 
may be difficult to turn the child even after a foot has been grasped. In 
the latter case it is advisable to bring down the second foot also, if this can 
be done, and to make traction upon both feet. In the former, one may 
succeed by turning the patient in the lateral position. Bringing down the 
posterior arm is an arduous task, and may require the introduction of the" 
entire hand into the vagina, a procedure which is likely to result in severe 
laceration. 

The delivery of the after-coming head may prove extremely difficult, 
and for this reason the services of a competent assistant should be secured 
if possible. The manoeuvre of Champetier de Ribes is very useful. The 
French accoucheurs have considered oscillating tractions of great value in 
the delivery of the after-coming head. In this country they were taught 
by Goodell many years ago. The trunk is alternately raised and lowered, 
a finger in the mouth keeping the head flexed. It is more effective, how- 
ever, to make the tractions on the shoulders alternately, an assistant making 
suprapubic pressure upon the frontal region, thus keeping the head flexed. 
If the child dies, tractions should be suspended and the after-coming head 
perforated. There is neither sense nor science in imperiling the mother 
in order to avoid a slight mutilation of a dead child. 

Prophylactic Version. — This method was formerly much employed. 
It consists in performing version and bringing down a foot early in labor. 
The foot serves, if necessary, as a handle in the subsequent delivery. The 
procedure is convenient and attractive and saves the attendant much 
anxiety. It is a great relief to him to know that he can terminate labor at 
any time, and furthermore version may be much easier early in labor than 
later. 

It has been urged, too, in its favor that rapid delivery is better for the 
mother than a greatly prolonged labor supplemented perhaps by a forceps 
operation. The extraction of the after-coming head may, it is true, be 
difficult and may be attended by severe laceration, but the long-continued 
pressure, with its train of evil consequences, sloughing, sepsis, etc., and the 
great attendant suffering is absent. The objection to this method is that it 
leaves the child largely out of account. A high proportion of children 
succumb to version in contracted pelvis and, as we know, many of these 
cases terminate happily if left to nature. It is evident that by this method 



CONTRACTED PELVIS 



535 



the fetal mortality will be considerably increased. It was a useful resource 
in the days when the Csesarean section was almost necessarily fatal, but 
should now be restricted to cases in which the circumstances are decidedly 
unfavorable to abdominal section, or the existence of some malpresenta- 
tions, e.g.. face or brow presentation, or posterior occiput, which render 
vertex delivery unlikely. 

The engagement of the head in the pelvic brim is sometimes favored 
by placing the patient in the Walcher position. In this position the hips 
are brought so far over the edge of the bed or table that the weight of the 
legs and thighs dragging directly downward (toward the floor) carries the 
symphysis in the same direction and thus temporarily increases the antero- 
posterior diameter of the brim. The space gained is small, one to eight 
millimetres, according to 
Pinzani, and few patients 
can be induced to^ main- 
tain it for a long time, 
hut in doubtful cases it is 
worth tr}'ing. An im- 
provement upon the or- 
dinar}^ method is that of 
Hirst, who puts a thick 
cushion under the pa- 
tient's back, meanwhile 
allowing her to remain 
in bed (Fig. 321). 

In some cases the en- 
trance of the head into 
the pelvic brim may be 
aided by strong pressure 
applied directly to the 
head through the ab- 
dominal wall, after the 
method of Hofmeier. The bladder must be empty and an anaesthetic will 
usually be necessary. It is evident that too great force or undue persistence 
in the effort may be productive of harm. 

But the reader must carefully avoid the idea that every case of pelvic 
contraction requires operative treatment. In some, indeed, there is little or 
no deviation from the mechanism or clinical course of labor. Now and 
then, much to the surprise of all concerned, labor runs an unusually rapid 
course. 

In the majority of cases, however, labor is prolonged to a greater or 
less degree and the delay, together with the attendant suffering, requires 
the solicitous attention of the physician. We have already spoken of the 
importance of asepsis, of the limitation of examinations, and of the 
preservation of the membranes. But the danger of infection, while perhaps 




Fig. 321. — Walcher posture. Black line denotes conjugate diameter 
of the brim. Space gained is a dotted continuation of this line. 



536 PATHOLOGY OF PREGXAXCY AND LABOR 

the greatest, is not the only danger. The ill effects of exhaustion and 
shock are not to be forgotten. The suffering is often exceptionally severe. 
Sometimes the patient undergoes a veritable martyrdom. When progress 
is arrested or becomes very slow the long continued reciprocal pressure 
between the head and the maternal circle of contact is attended by pain 
which, as Lusk was wont to say, exceeds that of the rack or the thumb 
screw.' Recalling these facts, the thoughtful and humane attendant wall 
not forget to see that his patient receives suitable nourishment and perhaps 
stimulation, and will endeavor to procure for her sleep, and as far as 
possible relief of pain. This is best accomplished in the first stage by 
moderate doses of morphine or chloral or both combined, and in the second 
bythe occasional inhalation of ether by the drop method. The " twilight,'' 
method, which undoubtedly prolongs the second stage of labor, is not to be 
advised in these cases. 

A pendulous abdomen, so common in pelvic contraction, is sometimes a 
very effectual obstacle to the progress of labor. This should be corrected 
by a bandage so arranged as to lift the fundus to its normal position and 
bring the uterine axis into coincidence with that of the pelvic brim. 

DeLee prefers the exaggerated lithotomy position. An assistant should 
keep the thighs firmly pressed upon the abdomen. Theoretically this posi- 
tion would seem to be contra-indicated, since it is supposed to widen the 
pelvic outlet rather than the inlet, but in these matters theoretical con- 
clusions should not be allowed to stand in the way. It is certainly a very 
effectual way of correcting a pendulous abdomen, and, since it imposes no 
great strain upon the mother, is well worthy of trial. 

Two or three careful examinations at intervals of an hour or two will 
suffice to show whether progress is being made. The examiner recalling 
the mechanism of labor in pelvic contraction will note that in flat pelvis 
the approach of the sagittal suture to the median line and, in general 
contraction, the descent of the posterior fontanelle, are favorable signs. 

The fetal heart should be carefully watched during the second stage 
and since the low operation imposes no serious additional risk to the mother 
the attendant will not hesitate to hasten delivery if it seems necessary in 
the interests of the child. 

If the head becomes impacted (wedged) in the pelvis in such a manner 
that it is apparent that a general " loosening "of the pelvic diameters is 
all that is necessary, if child is viable and if conditions, e.g., repeated 
examinations, etc., forbid Csesarean section, we have the typical indications 
for pubiotomy. But this indication is rarely present. Personally, I agree 
with Hirst that, as our results in the Caesarean section steadily improve, 
this operation will be for the most part abandoned, as has been the case 
with symphysiotomy. 

Before being subjected to pubiotomy, however, the patient is entitled to 
a trial of the axis-traction forceps in the hands of a good operator, if such 
can be secured. If the conditions are not favorable to the performance of 



CONTRACTED PELVIS 



537 



the Cc-esarean section or pubiotomy, the choice Hes between the forceps 
operation and version. The relative indications are much the same as 
those already stated. 

If the child is dead or positively non-viable, craniotomy may be per- 
formed. It is a popular mistake, however, to suppose that craniotomy is 
necessarily safer than the CcTsarean section. If the head is larger than we 
suppose, and this is often the case, and particularly if the measurements 
approach the lower limit, it may prove an exceedingly difficult operation, 
requiring much skill and experience in obstetric manipulation. Under 




Fig. 322. — The anterior and posterior sagittal diameters at the outlet. (Polak's Manual of Obstetrics, 

D. Appleton & Co.) 

these circumstances craniotomy, by a man unskilled in obstetric operating, 
is far more dangerous than the Caesarean section performed by a man who 
has a fair knowledge of abdominal surgery. 

The conduct of the second stage, if the patient is so fortunate as to reach 
the second stage without operative aid, does not differ materially from 
that which obtains in normal labor except that the fetal heart must be most 
carefully watched. Recalling the fact that the foetus has been subjected 
to long and severe pressure the attendant, if he finds any indications of 
impending asphyxia, will not delay the application of the forceps. 

If, however, the disproportion is too great, the pains become intolerably 



538 PATHOLOGY OF PREGXAXCY AND LABOR 

severe, assuming a character familiar to the experienced obstetrician. This 
is doubtless due to reciprocal pressure between the head and the pelvic 
hrim unattended by advance. There is no respite between the pains, as in 
normal labor. The continued pressure causes congestion and oedema of 
the vagina and vulva. The anterior lip of the cervix becomes enormously 
swollen and in rare cases the entire cervical ring may slough off and be 
discharged. If relief is not afforded the case goes on from bad to worse 
and the patient eventually dies from rupture of the uterus, sepsis, or 
exhaustion. Happily this picture is no longer seen. 

Treatment of Outlet Contractions. — \Mien the transverse diameter 
of the outlet is much diminished (according to Williams when it is less 
than eight centimetres) the occiput is arrested between the tuberosities and 
consequently the available space anteroposteriorly is represented by a line 
extending from the middle of the intertuberal diameter to the tip of the 
sacrum. This line represents what is called the posterior sagittal diameter 
(Fig. 322). 

It is obvious that if the transverse diameter is seriously diminished the 
posterior sagittal diameter must be proportionately increased, or labor will 
he delayed or perhaps completely arrested. Williams gives the following 
as showing the necessary proportions : 

Transverse diameter 8 cm., posterior sagittal 7.5 cm. 

Transverse diameter 7 cm., posterior sagittal 8 cm. 

Transverse diameter 6.5 cm., posterior sagittal 8.5 cm. 

Transverse diameter 6 cm., posterior sagittal 9 cm. 

Transverse diameter 5.5 cm., posterior sagittal 10 cm. 

These figures are subject to considerable variation, the size of the head 
"being an important factor, and in cases of doubt I am inclined to favor 
a careful trial of the forceps. In some apparently formidable cases nothing 
more serious results than a perineal tear. When the disproportion is too 
great, the Csesarean section should be performed ; or if the conditions are 
not favorable for this operation we may resort to pubiotomy. The technic 
of the forceps operation in outlet contractions is given later. 

It is said that the posterior sagittal diameter is increased by putting 
the patient in the semi-prone position and this expedient is well worth trial. 



PART III 

OBSTETRIC SURGERY 

CHAPTER XXIV 
GENERAL TECHNIC OF OBSTETRIC OPERATIONS 

Gexeral Remarks. The Improvised Operating Table. Position of 
Patient. Asepsis and Antisepsis. Postoperative Precautions. 

Obstetric surgen^ differs from other kinds of surgery in the fact that 
its operations are for the most part operations of emergency. They do 
not admit of delay. 

In general surgery and gynaecology the operator usually has time for 
preparation. He has a few days, or at all events a few hours, for reflection 
and study. He can appoint a time and a place for his operation, and in 
the meantime secure such advice and assistance as he may deem necessary. 
He can operate at the home of the patient or, if he so elects, can have 
her transferred to a hospital. 

How different it is in the practice of obstetrics we all know. The 
obstetrician has scant time for preparation or consultation. For some 
occult reason these operations must usually be performed in the middle 
of the night or in the early hours of the morning, when the operator, per- 
haps new to his work, is worn out by anxiety and loss of sleep. In many 
cases he must forego the advantages of professional assistance and skilled 
nursing, working with such assistance as he can command, performing the 
operation and supervising the anaesthesia at the same time, and all this in 
the presence of an excited and none too friendly audience. 

All this is calculated to embarrass and unnerve even those who are no 
longer novices and it is therefore desirable that every one who may be 
called upon to perform these operations should have a plan of campaign 
marked out in advance, and that he should so thoroughly master it, by 
memorizing its details, and by putting it into practice whenever oppor- 
tunity offers, that it will become part of himself, and that, even amid the 
most trying surroundings and under the most unfavorable circumstances, 
he will, as it were, automatically, do the right thing at the right time. 

Here, as elsewhere, individual preference and opinions will vary, and 
every man who does much obstetric work will in time develop a technic 
of his own. The following suggestions, which are the result of considerable 
experience in this field, may serve as a frame-work to which the prac- 
titioner may add as experience or judgment dictates. But first a word as 
to indications. 

539 



540 OBSTETRIC SURGERY 

The indications for the different operations will be given as we go on. 
There are a few rules, however, which apply to obstetric operations in 
general. 

In the first place a clear indication should be present. To operate in 
order to save time is never justifiable. If a man cannot aft'ord the time 
necessary to do justice to his patient, he should adopt a less arduous 
calling than that of the obstetrician. 

In doubtful cases the inexperienced obstetrician will usually do better 
to wait for a time, provided the condition of mother and child is good and 
suff'ering not excessive. 

On the other hand, if an operation is distinctly indicated the sooner it 
is performed the better. There are certain cases in which delay is perilous. 
For example, in transverse positions version is usually easy if performed 
early, but if delayed may prove difficult or even impossible. In placenta 
praevia delay may be fatal. In prolapse of the cord, or impending 
asphyxia of the foetus, prompt action is necessary, and so on. 

Before the administration of the anaesthetic is begun the operator 
should satisfy himself that he has at hand all the instruments, appliances 
and drugs that may be needed during, or immediately after, the operation. 
These should include a hypodermic syringe in working order with tablets 
of morphine, strychnine, etc., and above all some reliable preparation of 
ergot for hypodermic use. A fountain syringe and an intra-uterine douche 
tube, together with plenty of hot sterile water to be used in case of 
hemorrhage, also plenty of sterile gauze for packing the uterus, a tenacu- 
lum for drawing down a torn and bleeding cervix, needles and suture 
material. The latter should include silkworm gut and catgut. Time and 
trouble are saved by having a few needles threaded in advance. Sterile 
towels, absorbent cotton for sponges, and an abundant supply of lysol 
solution should also be at hand. Everything requisite for combating fetal 
asphyxia should be in readiness, including a tracheal catheter, preferably 
of metal, and oxygen if obtainable. 

It is most annoying to the operator, and, what is more important. 
detrimental to the interests of the patient, for him to be obliged to suspend 
an operation and to prolong the anaesthesia while searching for some 
necessary instrument, threading needles, or sending for assistance. 

\'\'hen an obstetrical operation is begun it is usually best to finish it at 
one sitting. Of course, there are exceptions to this rule. If a man 
attempts an operation and finds that its successful completion is beyond 
his power, he should at once desist from the attempt and send for such 
assistance as he may need. Again an operation may comprise two opera- 
tive procedures, e.g., a preliminary dilatation of the cervix. It is my 
experience that in such cases the first procedure is short and all usually 
goes well. On the whole, however, repeated attempts at delivery are not 
only demoralizing to the physician and to the family but they materially 
prejudice the interests of the patient. Repeated anaesthesias and attempts 



TECHXIC OF OBSTETRIC OPERATIONS 541 

at deliver}' with the necessary attendant manipulations rapidly exhaust the 
vitality of the patient and markedly increase the danger of hemorrhage, 
infection and shock, especially the latter. 

Let me repeat, then, that the young obstetrician will do well, before 
inidertaking serious or. doubtful obstetrical operations, to make sure, if 
possible, that everything that may be needed is at hand, not forgetting 
experienced advice if the circumstances will permit. The latter will not 
only aid him in promptly and successfully completing his work, but will 
afford him the moral support that is so necessary in the trying emergencies 
of early obstetrical practice. 

The Operating Table. — Obstetrical operations should be performed 
upon a table. It is quite true that the simpler operations, e.g., the low 
forceps operation, are often successfully completed in the cross-bed posi- 
tion, but he who always uses the table will in the end obtain better results 
and may now and then escape serious misfortune. 

The importance of obstetric surgery should not be underestimated. 
Xo one would think of trying to do an appendectomy or a herniotomy 
with the patient in bed and the operator kneeling on the floor. The 
operations which the obstetrician is called upon to perform are of at 
least equal difliculty, and they involve a more serious responsibility, since 
two lives are at stake. 

Then, too, the practice of obstetrics is full of surprises. The unex- 
pected difficulties of forceps operations are discussed elsewhere. Such 
difficulties often arise during the operation of version. It is always 
demoralizing, and sometimes dangerous, to stop in the midst of an opera- 
tion to change the position of the patient. Moreover, however simple the 
operation, it may be necessary to follow it by the repair of an extensive 
laceration, or by packing the uterus for hemorrhage. 

Last, but most important of all, the patient and her friends have a 
right to expect that operative procedures such as these should not be 
performed under such circumstances that delicacy of manipulation and 
thorough asepsis are alike impossible. 

In the hospital, of course, a special operating table is always at hand, 
but such a table is by no means a necessity. Almost any table that is 
strong enough to hold the patient will do. I have many times operated 
upon the dining-room table, and, indeed, I have found this more con- 
venient than the usual surgical table in most hospitals, which is altogether 
too high for the upward traction necessary in forceps operations. 

The table should be placed in a convenient light and covered with a 
blanket. Over this should be placed a sterile sheet or at least one fresh 
from the laundry. Underneath the buttocks of the patient may be placed 
a piece of rubber sheeting, or, in an emergency, white oilcloth, so arranged 
as to convey the discharges into a pail at the foot of the table and at the 
same time prevent. them from flowing backward toward its head. I have 
learned to dispense with the Kelly pad. While very convenient for curet- 



542 



OBSTETRIC SURGERY 



tage and other gA'nsecologlcal procedures, it is quite unsuited to such opera- 
tions as forceps and version, and is almost certain to be pulled from under 
the patient during the strenuous work so often necessary (Fig. 323). 




Pig. 323. — Improvised operating table in private house. The imitation Kelly pad is made of 
white oilcloth. It should be covered with a sterile sheet before the patient is placed upon the table.. 
The wash boiler in which the instruments have been boiled and from which they have been removed 
contains plenty of sterile water. The bowl on the chair contains lysol solution and sponges. Note 
among other things the rubber catheter on the table and the fountain syringe hanging on the wall;, 
both absolute necessities. 



I have also learned to dispense with legholders, considered so important 
by many, and always prefer to secure, if possible, the services of two 



TECHXIC OF OBSTETRIC OPERATIONS 543 

lay assistants, one to hold each knee. In this way the patient can be per- 
fectly controlled, a matter of great importance, since, as we shall see 
presently, profound and long-continued anaesthesia is highly undesirable. 
An additional advantage is that the legs and thighs can be flexed and 
extended at will and the position of the patient changed if necessary. As 
we have seen elsewhere, extension of the thighs during the stage of 
expulsion favors relaxation of the perineum. Then, too, in difficult version 
it may be desirable to turn the patient upon her side. An additional 
disadvantage of legholders, straps, etc., is, that the constriction of the 
legs by such apparatus may cause considerable pain and soreness, lasting 
for days after the operation. The assistants who hold the legs must, of 
course, be cautioned against coming in contact with the field of operation. 

In an emergency the legs may be held by a twisted sheet, but such an. 
arrangement is very frail and unsatisfactory, and every physician should 
carry with him an appliance like that of Robb. 
This may be removed when the head begins to 
distend the perineum (Fig. 324). 

The operator should avoid touching anything 
that is not sterile, and, since in certain cases, 
e.g., in version, it is absolutely necessary that he 
should make certain manipulations through the 
abdominal wall, the abdomen should at all times 
be covered with a sterile towel. Other sterile 
coverings are used as directed in the chapter on 
the management of normal labor. Let the oper- 
ator remember that wherever water can be boiled, 
there sterile dressings can be obtained. Trained 
nurses and hospital paraphernalia are very desir- 
able, but not absolutely indispensable. Now and 
then one meets a man who imagines that unless ^^^- 324.— Robb's leghoider. 
the patient is in a hospital or a good home it is useless to take any pre- 
cautions at all. This is very far from the truth, and to proclaim such 
ideas is most reprehensible. 

Anaesthesia. — The general subject of anaesthesia in obstetrics is dis- 
cussed elsewhere. It cannot be too often repeated, however, that in 
obstetric surgery the amount of anaesthetic administered should be strictly 
limited to the absolute necessities of the particular case. The attendant 
should never for a moment forget that in obstetrics there exist objections 
to any excess in this respect that do not obtain in other branches of sur- 
gery. In the latter the physician does not have to contend with the dangers 
of postpartum hemorrhage, fetal asphyxia, and preeclamptic toxaemia. 
The influence of prolonged anaesthesia, and especially of too much chloro- 
form, in causing or aggravating these conditions has already been noted. 
The administration of the anaesthetic should be delayed until the last 
moment, i.e., until the patient is on the table and the operator is ready to 




544 



OBSTETRIC SURGERY 



begin (Figs. 325, 326 and ^2']). A>ry often it takes but a moment to 
anaesthetize a woman who has been long in labor. Now and then I have 
seen an operator consume fifteen or twenty minutes in preparations that 
should have been made before, the patient meanwhile being profoundly 
narcotized. This is closely akin to malpractice. The attendant should 



^ 




Fig. 325. — Patient upon the table. A twisted sheet keeps the thighs flexed upon the abdomen. 

be content with primary anaesthesia whenever this will suffice, and should 
discontinue the anaesthetic as soon as possible. Ether should be preferred 
in all cases in which the patient has lost, or is likely to lose, much blood, 
e.g., in placenta prsevia and in certain cases of abortion. It should also 
be used in all anaemic or exhausted cases, e.g., in the induction of abortion 
for pernicious vomiting. Owing to the danger of delayed chloroform 



TECHNIC OF OBSTETRIC OPERATIONS 

Fig. 326. Fig. 327. 



545 







i 



I 
1 

{ 




\ 



J 




'^ 



Fig. 326. — Doctor's operating gown, cap, mask and gloves. 
Fig. 327. — Nurses operating gown, cap, mask and gloves. 

poisoning, chloroform should not be used in operations lasting more than 
twenty or thirty minutes. If an anaesthetic must be used after delivery, 
^.^.^ in perineorrhaphy or manual removal of the placenta, ether is to be 
35 



546 OBSTETRIC SURGERY 

preferred. Nitrous oxide should not be used before delivery without a 
plentiful supply of oxygen, as it rapidly asphyxiates the foetus. ]\Iy experi- 
ments in the administration of oxygen to pregnant women at the New York 
City Hospital indicate that it directly affects the foetus, and experience 
leads me to believe that the chances of the foetus are improved by freely 
combining oxygen with whatever anaesthetic is used in obstetric operations. 

Position of the Patient. — What position should the patient occupy 
during the operation? Usually the dorsal, since in this position the ana- 
tomical relations are more easily remembered and asepsis is more easily 
maintained. It is obvious that one cannot practise irrigation satisfactorily 
with the patient in the Sims position and the rectum on a higher level 
than the vagina. 

Nevertheless, there are exceptions to this rule, e.g., when it is proposed 
to introduce a tight vaginal tampon. As explained elsewhere, this can be 
more effectively done with the patient in the Sims position. Then, too, 
we shall see when we come to consider particular operations, that in using 
the axis-traction forceps and in the performance of version it is sometimes 
of great advantage to turn the patient upon her side. 

Nothing could be more provincial than to adopt some one position, 
because customary or traditional in a particular locality, and never deviate 
from it. 

The Bovv^els. — In obstetric operations there is usually no time to empty 
the upper bowel. One cannot wait for the action of a cathartic. But it is 
always wise to give an enema if circumstances permit. A pint of soapsuds 
with a drachm of turpentine works promptly and efficiently. A loaded 
rectum interferes, if not greatly at least to some extent, with the contraction 
of the uterus and the descent of the head, and during the emergence of the 
latter faeces are extruded, soiling the adjacent parts and increasing the 
danger of infection. 

The Bladder. — ^luch more important is it to empty the bladder. The 
catheter should never be left at home. Barnes, the well-known English 
obstetrician, was wont to advise his students to have a catheter tied to the 
forceps that they might not forget to empty the bladder before using the 
instrument. We may not follow this advice literally, but we should not 
forget the principle iuA^olved, one of the most important in obstetrics* 
Before every important obstetrical operation, whether it be the forceps 
operation, version, breech extraction, the Caesarean section, or craniotomy, 
the bladder should be carefully emptied as the final step in preparation. 
Sometimes, indeed, this is all that is needed. I recall a case in which I 
was called upon to operate, the delay being attributed to pelvic contraction. 
A superficial examination at once disclosed the cause of delay. The 
bladder was enormously distended. The only instrument necessary was 
the catheter. 

The glass catheter is here an absurdity. It may break, and it often. 
fails to reach the bladder. A long, soft, rubber instrument which has 



TECHXIC OF OBSTETRIC OPERATIONS 547 

been sterilized by boiling should always be at hand and should be intro- 
duced to its full length. It is occasionally, though not often, necessary to 
elevate the hips and push the head up a little in order that the instrument 
may pass without difficulty between the head and the symphysis. 

Asepsis and Antisepsis. — This subject we have already considered, 
but an additional word of caution is necessary. The operator must not 
forget the disinfection of the patient. If a competent trained nurse is 
present she will attend to this matter, but if not, the physician must attend 
to it himself. 

Here it is well to obser^x a definite order of procedure. Before touch- 
ing the patient at all the operator disinfects his hands according to the 
methods already described, in order that he may not infect his patient 
during the process. Then, lest he may have contaminated his hands he 
redisinfects them and is ready to proceed. This double disinfection 
requires extra time, but it is time w^ell spent and the operator can proceed 
with a clear conscience. This conduces not a little to his peace of mind 
and thus indirectly to the success of the operation. 

The preliminary' disinfection of the patient should never be omitted. 
It consists in a thorough cleansing and scrubbing of the external genitals 
and also of those adjacent parts of the body, the abdomen and the thighs, 
with which the hands are almost certain to come in contact at some stage 
of the operation, first with soap and water and then with lysol solution. 
Cotton sponges are to be preferred to a stiff brush as effecting the same 
object with less traumatism. The hair about the vulva should be cut close 
with scissors. This is preferable to shaving the parts, which is not only 
unnecessar}^ but objectionable as causing many scratches and abrasions 
of the epithelium, which may become the site of infection. 

Experience long ago convinced me that preliminary douching or scrub- 
bing of the vagina is not necessary. In fact, I believe that it does harm 
rather than good, by diluting or washing away the protective secretions 
furnished by nature. Rubber gloves should be worn, especially after 
exposure to contagious diseases or infectious cases, and should always 
be carried by the practitioner to be used in those rare cases in which some 
great emergency, e.g., severe hemorrhage, renders it impossible for him 
to take as much time as he would like to take in the process of hand disin- 
fection. For such emergencies and for all cases in which the hand must 
be introduced into the uterus, gloves are indispensable. Those of the 
gauntlet variety are preferable. 

During the course of the operation the vulva and adjacent parts, espe- 
cially the anal region, should be irrigated frequently from before backward 
with lysol solution. Some writers advise that the anus be covered with 
a sterile towel held in place by adhesive plaster. This works well in curet- 
tage, the repair of a torn cervix, and other semi-gyn?ecological operations, 
but during delivery, whether normal or operative, faeces are pressed from 
the rectum and the presence of the towel merely results in smearing them 



548 OBSTETRIC SURGERY 

over the surrounding parts and markedly increasing the danger of infection 
"by the colon bacillus. 

It is the custom with some operators to wash out the uterus after all 
operations in which the hand or instruments are introduced into its cavity. 
I long ago abandoned this practice and have had no reason to regret it. I 
helieve that it is, to say the least, unnecessary. Careful asepsis during the 
operation and strict external cleanliness following it give the best results. 

Final Examination. — When at length the patient is clean, anaesthetized, 
catheterized and in position upon the improvised operating table, there 
remains one further preliminary which should never be forgotten. The 
final examination for diagnosis. The failure to make such an examination 
is to be regarded as a serious error. Previous examinations have perhaps 
l»een unsatisfactory. Sutures and fontanelles may have been difficult of 
access or obscured by the presence of a large caput succedaneum. Thor- 
ough exploration may have been prevented by the resistance of the patient 
or by a commendable desire upon the part of the attendant to avoid the 
infliction of annoyance and unnecessary pain. But now with the patient 
mercifully unconscious of suffering, the muscles of the abdomen and pelvic 
floor relaxed, and the rectum and bladder empty, the half -hand, if neces- 
sary, may be introduced into the vagina and the exact condition of affairs 
determined. Grave consequences have often resulted from neglect of this 
examination. The most common mistake in my experience is the failure 
to recognize a posterior position of the occiput. If under these circum- 
stances the forceps are applied without reference to the position of the 
head and an attempt made to overcome obstacles by force, the results may 
be disastrous for both mother and child. ]\Iany other mistakes which 
might result will at once occur to the reader ; e.g., the failure to recognize 
moderate, or even marked, pelvic contraction. 

Attention to the Foetus. — Obstetric operations differ from other 
operations in many ways, but in none, I think, more than in the fact that 
the operator is responsible for two patients at one and the same time. 
This is too often forgotten. Before every operation the fetal heart should 
be auscultated. If it cannot be heard, or if for any other reason the 
operator is apprehensive as to the safety of the child, he should inform 
some responsible member of the family. In this way he may escape 
tnideserved criticism. At frequent intervals during the operation auscul- 
tation should be repeated and both in study and practice the physician and 
student should pay special attention to those points in the technic of 
obstetric procedures as relate to the foetus. These are considered in con- 
nection with the different operations. Time devoted to this subject is well 
spent. 

When the operation is over the attendant should never forget to deter- 
mine the existence of lacerations and to make any needed repairs. In his 
joy at a successful result or his anxiety as to final outcome he should not 
forget to see that his patient is properly cleansed and left in an aseptic 



1 



TECHXIC OF OBSTETRIC OPERATIONS 549 

condition. The neglect of this precaution may undo all the good that has 
been accomplished. The cleaning up process, however, should be con- 
ducted with as little disturbance as possible. 

Perineal tears should be repaired at once if the patient's condition 
permits and the attendant circiuiistances are favorable. As we have noted 
above, this may not always be advisable after prolonged and severe opera- 
tions, but in such cases repair should be postponed until the next day — 
not omitted. Tears of the cervix sufficiently extensive to cause noticeable 
hemorrhage should, of course, be repaired at once. Such tears should 
always be thought of and sought for after high or median forceps 
operations, versions, and the induction of labor. 

Some recent writers advise that after all obstetric operations the interior 
of the uterus be palpated lest a rupture be overlooked. This seems to me 
a flagrant instance of meddlesome midwifery, the general adoption of 
which would do more harm than good. 

Before leaving the patient, the attendant should note carefully her 
facial appearance and general condition and the degree of uterine 
contraction. 

After all, except the easiest, operations the patient should remain abso- 
lutely quiet in the dorsal position and with the head low for at least twenty 
or thirty minutes. Xor should she be removed to her bed until the attend- 
ant is satisfied that there is no immediate danger of hemorrhage. During 
her removal from the table to the bed the head shuuld still be kept low and 
no voluntary effort on her part should be permitted. It is highly desirable 
that the patient be carefully watched for at least two hours after delivery. 
Before leaving the patient the attendant should make careful note of her 
facial appearance and general condition and of the degree of uterine, 
contraction. 



CHAPTER XXV 

PROCEDURES DESIGNED TO OVERCOME THE 
RESISTANCE OF THE CERVIX 

Manual and Instrumental Dilatation of the Cervix. The Vag- 
inal Cesarean Section. Incision of the Cervix. The Tampon. 
Sponge Tents. The Fcetus as a Dilator 

Artificial Dilatation of the Cervix 

When the cervix is imdilated or only partly dilated and some emergency 
arises which seriously threatens the welfare of mother and child and 
makes delivery advisable, artificial dilatation of the cervix may become 
necessary. Those who do much obstetrical work will frequently have 
occasion to practise such dilatation and will do well carefully to consider 
the principles that underly this procedure, the conditions that justify it, 
and the technic of its performance. 

Varieties. — Generally speaking, there are two methods of dilating 
the cervix artificially — manual and instrumental. In the first case, 
dilatation is effected by the hand of the operator and by this alone. 
In the second, various instruments and appliances of rubber, steel and 
gauze are employed. Let us first consider the simpler method of manual 
dilatation. 

Indications. — Any condition in which prompt delivery is indicated 
may constitute an indication for manual dilatation. Typical examples of 
such an indication may arise in the course of eclampsia, placenta prsevia, 
and prolapse of the cord. As we shall see later, it is a necessary pre- 
liminary to all forceps operations and to all versions, unless dilatation 
is already complete. It cannot be too often repeated that neither of these 
operations should be undertaken in the presence of an incompletely dilated 
cervix. A single, but important, exception is to be found in the case of 
placenta pr?evia, q.v. 

^Manual dilatation is a valuable adjuvant in the treatment of certain 
cases of delayed labor, and is sometimes employed to save time and pro- 
longed manipulations when the cervix has already been partly dilated by 
bags or other instruments. 

Centra-indications. — Alanual dilatation should not be undertaken 
when the cervical canal is preserved in its entire length. The condition 
of the cervix is approximately that of the non-pregnant condition, or of 
early pregnancy. It has not as yet undergone the necessary physiological 
softening and partial obliteration that are part of the latter weeks of preg- 
nancy and the early hours of labor. It is perfectly plain that such a cervix 
cannot be dilated manually except by the use of brute force — a process not 
550 



RESISTANCE OF THE CERVIX 



551 




of stretching but of tearing. 
This is the so-called accoiicJic- 
iiioit force, deservedly obso- 
lete and far more dangerous 
than the Ca?sarean section. 

When the internal os has 
been effaced and the canal 
partly obliterated manual dila- 
tation is possible, but should be 
undertaken only in exceptional 
cases, e.g., a partial dilatation 
in placenta prasvia with severe 
hemorrhage. 

^^llen the internal os has 
disappeared and the oblitera- 
tion of the canal is complete, 
the conditions are more favor- 
able. 

The above remarks refer 
to patients at term. ^Manual 
dilatation of the cervix is 
often difficult in the seventh 
or eighth month, even when 
the canal has been taken up. 
In these cases the slower 
m.ethods are usually to be pre- 
ferred. Manual dilatation is 
essentially a procedure for 
patients at or near term. 

Finally manual dilatation 
should never be practised sim- 
ply to save time, but should be 
reserved for cases in which it 
is distinctly indicated. 

Technic. — The bladder 
and the rectum should be 
empty. The operator should ♦^^ 
w^ear rubber gloves and every 
aseptic precaution should be 
observed. 

Several methods are in 
vogue. That of Harris is 
perhaps the most popular and 
is, without doubt, the most 

convenient and effective. The Fig. 328.— Bimanual dilatation of cervix. (After Edgar.) 



552 OBSTETRIC SURGERY 

hand is introduced into the vagina and the index finger passed through 
the cervix. The thumb is then inserted alongside the finger by a pecuhar 
movement hke snapping the finger slowly. The second, third and fourth 
fingers, and finallv the thumb, are then introduced in a similar manner. 

In the bimanual method practised in France by Bonnaire, in Scotland 
by Simpson, and popularized in this country by Edgar, both hands are 
opposing, pressure being made in various directions successively (Fig. 

328). 

Both these methods are capable of rendering excellent service, and may 
be used according to the circumstances of the particular case or alter- 
nately in the same case. Harris's method is much more convenient when 
the cervix is high and difficult to reach, but has one disadvantage, viz., 
that it is necessary to introduce the entire hand into the vagina, which 
is highly undesirable if the operator has a large hand and the vulval orifice 
is small, as in primiparse. Edgar's method is more convenient when the 
cervix is low and easily reached, as it usually is in primiparse, but the 
operator must guard against the temptation to use too much force or to 
proceed too rapidly. 

In a comparatively large experience I have found it better to begin 
by simply hooking one finger into the cervix and drawing it down, making 
gentle but continuous pressure on difi^erent parts of the circumference of 
the resisting os. After a few moments a second finger can be introduced, 
and the process is repeated with two fingers, the fingers being at the same 
time separated so as to stretch the cer\4x successively in all its diameters. 
The operator should work slowly and carefully, taking 25 or 30 minutes 
by the clock, as Williams has well said. I have not usually found it 
necessary to introduce the hand into the vagina, nor to employ more force 
than can be exerted by separating the fingers. 

If a contraction comes on while the operation is in progress all efforts 
at dilatation should be suspended until the contraction is over, the cervix 
meanwhile being allowed to contract upon the fingers. AMien four fingers 
can be introduced and separated, sufficient dilatation has been secured. 
The operator should not stop here, however, but should allow the cervix 
to contract for five minutes longer upon the separated fingers, thus not 
only dilating, but temporarily paralyzing it, and preventing its recontrac- 
tion ; an artificiaUy dilated cervix has a tendency to rccontract. This com- 
plete dilatation and paralysis of the cervical sphincter in manual dilatation 
is also the best method of preventing bad tears of the cervix during the 
subsequent delivery. Experience has taught me that such tears are not 
likely to result from any force that can be exerted by the mere separation 
of the fingers. They are usually caused by the rapid passage of the fetal 
head through a cervix that is but partially dilated. 

In many, indeed in the majority of, cases in which manual dilatation is 
indicated, the cer^nx is already partly dilated and dilatation is easily 
completed by this method 



I 



RESISTANCE OF THE CERVIX 553 

All haste and the use of brute force should be avoided. The operator 
should remember that the effort at dilatation, properly performed, acts by- 
tiring out not tearing apart the cervical sphincter. 

A word of caution is necessary, however. Do not keep the patient 
continuously profoundly narcotized all this time. Primary anaesthesia 
is usually sufficient. AMien the dilatation is to be followed by operative 
delivery, as is so often the case, no one knows how long the entire 
procedure may last and the careful accoucheur is never unmindful 
of the dangers of prolonged and profound anaesthesia. Ether is usually 
to be preferred. 

If the hand of the operator becomes cramped and disabled, as often 
happens, relief may be obtained by immersing it for a time in hot water, 
continuing the dilatation meanwhile with the other hand. 

To Sum Up. — ^lanual dilatation of the cervix is one of the most 
important operative procedures in obstetrics. If it were more extensively 
taught and better understood many more serious operations might be 
avoided. 

]*^Ianual dilatation can be safely practised only when the cervical canal 
is nearly or quite obliterated. 

Xo more force should be used than can be exerted by separating the 
fingers. 

Profound anaesthesia is not necessary and should be avoided. 

If dilatation is to be followed by forceps or version it should be 
complete, and should be maintained for at least five minutes in order 
that the cervix may be temporarily paralyzed and recontraction 
prevented. 

The introduction of the hand into the vagina is not usually necessary 
and should be avoided if possible. The half-hand is usually quite sufficient. 

A\'hatever method is adopted, the operator should work slowly and 
gently, remembering that his purpose is to be effected, not to. over- 
come obstacles by force, but by gradually tiring out the constricting cervical 
ring. 

Instrumental Dilatation 

A'arious instruments and appliances are used in dilating the cervix. 
Among these are the hydrostatic dilators — rubber bags filled with a weak 
antiseptic solution, the vaginal and cervicovaginal tampon, sponge tents, 
and certain steel dilators, of which we shall speak presently. 

The bags of Barnes and de Ribes are shown in Figs. 329 and 330. 
The " dumbbell " bag of Barnes served a useful purpose in its day, but is 
now of historical interest only, having been superseded by the more useful 
and practical bag of de Ribes. The trouble with the Barnes bag was 
that it would not remain in position. It was constantly slipping out. The 
great advantage of the de Ribes bag is that, owing to its shape, it cannot 
slip out until the cervix has become dilated to the size of the greatest 



554 



OBSTETRIC SURGERY 



diameter of the bag. A glance at Fig. 329 makes this perfectly plain. 
Further advantages of the de Ribes bag are that it serves perfectly the 
purpose of a dilating body, its shape resembling that of the " bag of 

waters," and its mode of action being a 
close imitation of the natural mechanism, 
and that, by the m.eans of the tube 
attached, traction can be made and uterine 
action stimulated if necessary. 

A^oorhees's modification, which is 
essentially a de Ribes bag, so modified by 
using a thicker rubber, by substituting 
canvas for silk as a foundation, and by 
carefully sewing and cementing the seams 
as to render it much stronger and more 
durable, is extensively used and has 
proven very satisfactory. 

Indications. — Hydrostatic dilatation 
is of use in a great variety of con- 
ditions in which we desire to induce 
labor or to hasten its progress. It is, 
in mv opinion, the best method of inducing labor when the patient is 
near term and the cer\'ix can be made to admit the finger. It is also useful 
in hastening the progress of labor when the presenting part is a poor dilator 





Fig. 329. — Barnes bags. 




Fig, 330. — Champetier de Ribes bag folded on itself. 



of the cervix, as in "' dry labor '" and breech presentation, and it has been 
used to prevent the descent of the cord in cases of prolapse and to prevent 
or restrict hemorrhage in certain cases of placenta prsevia. It is a favorite 
method of hastening cervical dilatation in eclampsia. 

Many writers evidently regard the introduction of the bags as a 



RESISTANCE OF THE CERVIX 



555 



procedure only to be undertaken by one who has attained considerable 
technic. To my mind this is a mistake and has caused many a competent 
man to forego advantages that should have accrued to him and his patients. 
Certainly any man who is competent to undertake a forceps operation is 
competent to insert one of these bags. 

Technic. — The patient should be in the dorsal position. The bladder 
should be empty. The preparation of patient and operator are the same 
in everv detail as for the induction of abortion, already described. Rigid 




^ ^3 







Fig. 331. — Introduction of the de Ribes bag. An assistant is holding the cervix with two tenacula. 

asepsis must be maintained. The bags will stand boiling several times, 
and should he boiled. Immersion in an antiseptic solution is not sufficient. 
The operator should remember that he is introducing a foreign body into 
the uterus and that this is always a serious matter. This is especially 
important in cases of low insertion of the placenta, in which all the 
manipulations are in the danger zone whence venous channels lead directly 
into the general circulation. 

When all is ready, the cervix is exposed by means of an Edebohls 
speculum, and fixed by two tenacula. If the case is a suitable one for the 



556 OBSTETRIC SURGERY 

operation, little or no force will be necessary to pass the gloved finger 
througn the cervix. In many cases two fingers may be passed. Cases in 
which the cervix is long and hard and the canal preserA-ed — in other words, 
cases in which there must be considerable dilatation with the steel dilators 
before the tip of the finger can be introduced — are not, in my opinion, 
adapted to this method of delivery. In such cases some degree of pre- 
liminary softening and dilatation should be first attained by tamponing 
the cervix and lower uterine segment with gauze. 

The operator now takes the bag in his hands, inverts its conical base, 
folds the bag upon itself, grasps it with the forceps, and passes it through 
the cervix under the guidance of the eye (Fig. 331). \\'ithdrawing the 
forceps, he holds it in place with the finger and makes sure that the greatest 
diameter of the bag is well above the internal os. An assistant now fills 
the bag by injecting sterile water into the tube, or the operator may do 
this himself, as shown in Fig. 332. A piece of tape is now tied tightly 
about the tube to prevent the escape of the contained fluid. Some advise 
an artery-clamp . for this purpose, but I have found that it is apt to cut 
through. Tape and tube, both sterile, are now coiled up and left in the 
vagina. The operator satisfies himself that the bag is well distended^ 
places a sterile pad over the vulva, and awaits results. 

The introduction of the bag is often a simpler matter than would appear 
from the above. In easy cases, e.g., in the case of a primipara with the 
fetal head well down in the cavity of the pelvis and the cervix dilated to 
the extent of admitting one or two fingers, I have had no trouble in intro- 
ducing the bag by the sense of touch alone, passing it through the cervix 
with two fingers and using no instruments whatever. It seems evident, 
however, that there is less danger of infection if the bag is passed directly 
from the sterilizer into the uterus, under the guidance of the eye. 

Contractions usually come on within a few hours. The bag excites 
these rather by the reflex irritation due to its presence within the cervix 
than by any direct pressure which it exerts. If, however, the uterus is 
slow in responding, as it often is in toxsemic cases, traction may be made 
upon the tube. \Mien the cervix has been dilated to such a size that the 
unruptured bag is expelled, a larger one may be inserted, provided labor 
is not well under way. Frequent renewals of the bag, however, involving 
repeated manipulations, and, in sensitive patients, repeated anaesthesias, 
are demoralizing and dangerous, vastly increasing the risk of infection, as 
well as destroying the confidence of the patient and her friends. If active 
labor does not supervene after the cervix has been dilated to the size of 
Xo. 3, a very gentle manual dilatation, followed by the rupture of the 
membranes, and perhaps by the exhibition of pituitrin, will almost certainly 
produce the desired result. 

The action of the bag is made more rapid and certain if before its intro- 
duction the operator separates the membranes from the uterine wall with 
the fino-er passed through the internal os as high as he can reach. This 



RESISTANCE OF THE CERVIX 



557 



is not usually necessary, however, and in the absence of an urgent indi- 
cation is obviously undesirable. 

Steel Dilators. — Xeither manual dilatation nor dilatation by rubber 
bags can be safely practised in early pregnancy. Even in the latter months, 
as long as the cervix is closed and its canal preserved, some preliminary 
dilatation must be secured before either of these procedures can be 
employed. In the last month of pregnancy, however, the cervix, especially 
in multipara?, easily admits the finger and no preliminary dilatation is 




Fig. 332. — The bag being in place the operator fills it with sterile water by means of the syringe. 

required. Even though the cervix be closed, the tissues are usually soft 
and distensible and dilatation may easily be accomplished with the finger. 
Whenever the latter will serve the purpose it is to be preferred to any 
steel instrument. With the finger carefully used there is much less dang-er 
of laceration, and one can better estimate the amount of force employed. 
Many operators advise and practise the use of steel dilators whenever 
the case is not suitable for dilatation by the finger. I would earnestiv 
advise the reader against this practice. If time permits, and there are few 
cases in which it does not, it is far better to pack the cervix and vagina 



558 OBSTETRIC SURGERY 

with gauze and allow at least twelve hours for preliminary softening and 
dilatation of the cervical canal. 

If the use of the steel dilators is deemed unavoidable, I prefer the 
graduated dilators of Hegar or Hanks as far safer than the branched or 
" glove stretcher " dilators in common use. The latter often produce 
severe laceration. There is no reason wdiy we should not treat the cer\dx 
uteri with as much respect as we do the male urethra. If the branched 
dilators are used those of Goodell, in which the separated blades remain 
parallel to each other, are much safer than those ordinarily used. 

This important subject is discussed at length in connection with the 
induction of abortion and of premature labor. 

The Dilator of Bossi. — There is one steel instrument which is used 
not for preliminary but for complete cervical dilatation, the dilator of 
Bossi. True , there have been A-arious modifications, but all embody the 
same principle. The parent instrument of Bossi has four arms, which 
are passed through the cervix and gradually separated by turning the 
screw at the handle. It is claimed that by means of this instrument com- 
plete dilatation can be attained in from fifteen to thirty minutes, even 
though the cervix be closed and its canal preserved. 

I have never had occasion to use this instrument and I would say of 
its use as I said of the so-called accoiicJieiiiejit force, and this method 
seems a sort of mechanical accoucliement force, that when manual dila- 
tation will succeed such an instrument is not necessary, and in the \tvy 
rare cases in which immediate delivery per vias nafurales is urgently indi- 
cated, the vaginal Csesarean section is far safer. It is, indeed, true that 
the cervix may be dilated, or rather divulsed, by this instrument, but it is 
difficult to believe that such divulsion does not imperil the integrity of the 
maternal structures or that it does not leave the ceriax in such a condition 
that the subsequent delivery involves extensive laceration. 

There are certain methods of securing cervical dilatation which are 
neither manual nor, in the usual sense of the term, instrumental. They 
may be classified here tmder three heads : i. The tampon. 2. The sponge 
tent. 3. The foetus itself. 

The Tampon. — Of these, and indeed, when time permits, of all 
methods, the tampon is by far the safest and therefore the best. Dis- 
tention of the vagina excites uterine contractions and these produce 
a gradual softening and dilatation of the cervix, just as nature performs 
this task in abortion or premature labor. If the cervix and lower uterine 
segment are also tamponed the result is more prompt and certain, but the 
vaginal tampon is usually sufficient. The disadvantage of the tampon is 
that its employment requires more time. Its advantage is that the 
danger of severe cervical laceration is minimized. Questions of time 
or convenience should have no weight with the physician wdien the welfare 
of the patient is involved. The technic is given in connection with the 
induction to be presently described. 



RESISTANCE OF THE CERVIX 559 

Sponge Tents. — AMien a piece of dried sponge, commonly called a 
sponge tent, is introduced into the cervix it imbibes fluid from the sur- 
rounding tissues and swells to a larger size. This dilates the cervix and 
reflexly excites uterine contractions. Dilatation by tents was formerly 
much in vogue and is still practised by some. It is difficult, however, to 
render a tent aseptic and it is unlikely that the tent will remain germ-free 
during the long process of imbibition. Moreover, various observers have 
reported cases of infection following the use of this agent, and we have 
in the cervicovaginal tampon a safe and effective recourse. 

The Foetus as a Dilator. — Finally, the foetus itself may be used as a 
cer^-ical dilator. For example, in abortions at the fifth or sixth month, 
before the period of viability of the child has been reached, a foot may 
protrude through the cervix, or the attendant may perform version and 
bring down a foot. Forcible dilatation is here out of place, since the mere 
presence of the thigh or half breech in the cervix is sure to cause ultimate 
relaxation. Should haste be necessary moderate, but not forcible, traction 
may hasten the process. Here, of course, the interest of the child does 
not come into question. ]\Iuch harm is often done in the effort to hasten 
the deliver}' of a foetus which could not possibly survive. 

The same condition may arise in the course of version for placenta 
pr?evia. after the period of viability has been reached. Here, of course, 
the version is performed primarily to arrest hemorrhage, the question of 
dilatation being secondary. As we shall see later, rapid extraction is here 
especially dangerous to the mother. 

The Vaginal Cesarean Section 
In 1906 the fertile and brilliant mind of Diihrssen devised an operation 
popularly known as the vaginal Caesarean section, but more correctly called 
anterior vaginaF hysterotomy, designed for those cases in which some 
serious emergency demands the immediate emptying of the uterus in the 
shortest possible time. 

FIRST STEP 

The anterior lip of the cervix is seized and drawn down by the traction 
forceps or traction ligatures, one on either side of the median line. The 
ligatures are preferable as taking up less room than forceps and affording 
a more secure grasp. A third ligature in the posterior lip may prevent 
one of the anterior ones from cutting through. 

A transverse incision about 6 centimetres in length is then made in the 
anterior ctd de sac at the cervicovaginal junction. A sound in the bladder 
enables the operator to locate that organ and thus avoid injuring it. The 
beginner should always adopt this precaution (Fig. 333). The bladder 
is then pushed upward by means of the finger wrapped in sterile gauze, 
well above the internal os and held upward and forward by a broad 
speculum like that of Pryor. This freely exposes the cervnx and lower 
uterine segment (Fig. 334). 



t 



\ 




■'^^^^^^^^^^ 



.-# 



r . 







"I 

So: 



/• 



RESISTANCE OF THE CERVIX 



561 



SEcoxD step: the uterine incision 
^^l^le one assistant holds the bladder upward and forward, out of the 
way, by means of the speculum, and the other draws the cer\4x downward 
by traction ligatures or forceps, the operator, under the guidance of the 
linger passed within the cervix, makes an incision with a pair of strong, 
straight, blunt-pointed scissors. This incision divides the cervix and the 




■^p'^ 



Fig. 335. — Vaginal hysterotomy. Longitudinal, median incision. 



lower uterine segment. It should be exactly in the median line in order to 
ai'oid the lateral branches of the uterine arteries (Figs. 335, 336 and 337). 
There is usually very little hemorrhage. The incision should not exceed 
ten or eleven centimetres in length. If it does it is likely to pass the point 
where the peritoneum is adherent to the uterus. On the other hand, if it 
36 








O +j 
■:;! in 

.:£ o 



.2^ 



o " 



RESISTANCE OF THE CERVIX 563 

is too short it may tear and thus open the peritoneal cavity. A very useful 
suggestion of Jeannin is that the assistant seize the tissues on either side 
of the incision with the traction forceps and make downward traction, 
taking a new hold higher up at intervals as the operator prolongs his 
incision. This facilitates the work remarkably. 

Diihrssen himself advises that a large de Ribes bag be introduced 
and used as a guide instead of the finger. This also draws down the cervix, 
making it more accessible. He also states that there is a tendency to 
relaxation of the uterus after this operation. This we would naturally 
expect to follow such a sudden evacuation of the uterine contents, and 
it is probably wise to follow Diihrssen's suggestion and pack the uterus 
with gauze before suturing the incision. 

THIRD STEP : DELIVERY OF THE FCETUS 

The membranes are now ruptured and the foetus is extracted by forceps 
or version, according to indications. The man accustomed to obstetrical 
operating will perhaps succeed better by version, but if the head presents 
at the opening and the attendant is a skilled obstetrician, the forceps should 
be applied, being equally safe for the mother and far less dangerous for 
the child. If the latter is dead, craniotomy should be promptly performed ; 
if it is of unusual size, a posterior incision may be necessary. In making 
the posterior incision the cervix is seized by a traction forceps and drawn 
upward toward the symphysis. The incision is made as already described, 
but the longitudinal incision should not be more than half as long as the 
anterior one. Bumm, in 52 cases, has not found the posterior incision 
necessary, ^[y own opinion is that if a posterior incision must be made 
before the foetus can be extracted it is evident that the case was one for 
delivery by abdominal, not vaginal, section. 

As a rule it is better to deliver the placenta manually, taking care to 
remove the membranes at the same time. Anterior hysterotomy is, or, at 
all events, should be, performed only in critical cases, and in such cases 
one does not like to prolong the anaesthesia. Moreover, if, as is so often 
the case, there is a tendency to uterine relaxation, it is not well to delay 
packing the uterus. 

Unless good contraction ensues, and all hemorrhage ceases, the uterus 
is now packed with sterile gauze. This is done after the posterior incision, 
if there be one, is closed, and before the sutures are placed in the anterior 
wall. 

FOURTH STEP : CLOSURE OF THE INCISIONS 

The incisions are closed by interrupted sutures of medium gut, which 
should stop just short of the mucous membrane. The vaginal mucosa is 
closed by a continuous suture of fine gut (Fig. 338) . The suturing is much 
facilitated by placing a traction suture at a convenient height and making 
traction on this while other sutures are being placed. This not onlv facili- 



564 



OBSTETRIC SURGERY 



tates the process, but aids to check any bleeding which resuhs from the 
incision. I have often noted the good effect of traction in temporarily 
arresting hemorrhage from a lacerated cervix. The operator should not 
forget that pressure upon the fundus makes the cervix much more 
accessible. 



>^ 




' • / 

Fig. 338. — Vaginal nysterotomy. Suture of anterior incision. 

Advantages. — The undeniable advantages of this operation are its 
simplicity and rapidity of execution, and the fact that it does not involve 
the peritoneal cavity. It can be completed in from 20 to 30 minutes by 
any man of fair surgical training, even if the cen-ical canal persists, and is 
far safer than forcible attempts at dilatation by the hand or by steel 
instruments. It makes a clean cut wound in the least vascular portion 



RESISTANCE OF THE CERVIX 565 

of the uterus, one that can easily be sutured under the guidance of the eye, 
instead of a ragged and dangerous wound extending perhaps out into 
one of the broad hgaments, one that cannot be sutured at all. Its very 
advantages, however, have led to its too frequent employment. 

Disadvantages. — Bad after-effects are often observed. As might be 
expected, union is often imperfect. A'esicovaginal fistula has been 
obsenxd. The liability to rupture in a subsequent pregnancy should not 
be forgotten. A'oorhees reports that in the examination of a large number 
of cases in which the operation had been performed by good operators, 
he has always found some disability, such as deep fissures in the anterior 
lip, erosions, granular inflammation, pain, leucorrhoea, etc. These conse- 
quences must, of course, be disregarded if the condition present involves 
imminent danger, but they are quite sufficient to condemn its performance 
in cases in which the tampon or the rubber balloon will serve the same 
purpose. Another disadvantage is the fact that the safety of the child 
is not practically guaranteed, as in the abdominal Caesarean section. If 
any mistake has been made in the estimation of its size, or if the operator 
is not a competent obstetrician, extraction may present unexpected 
difficulties. 

Indications. — This operation may be indicated when prompt delivery 
is necessary and the condition of the cervix or the necessity of great haste 
forbids manual dilatation. These indications are considered elsewhere in 
connection with the pathology of labor, and it is unnecessary to repeat them 
here. One thing, howcA'cr, should be emphasized. The operation has of 
late become fashionable, and there is good reason to believe that it has been 
too readily and too lightly undertaken. For example, it is an absurdity and 
an injustice to the patient to perform hysterotomy in placenta prsevia at 
five or six months, or for the delivery of a dead or non-viable foetus. I 
have known it to be performed when a simple cervicovaginal tamponade 
would have answered every purpose, and I have no hesitation in saying that 
the man who finds it necessary to practise this procedure very often, while 
he may be proficient in surgery or in pure gynaecology, is not a competent 
obstetrician. 

Nevertheless, it must be admitted that it is an ideal method in certain 
cases, chiefly in those cases which were formerly treated by the so-called 
accouchement force. Typical indications are to be found in severe cardiac 
and pulmonary crises with threatened pulmonary oedema, and in bad cases 
of accidental hemorrhage. Here the saving of time is of prime importance. 
Again, cicatricial or carcinomatous hardening of the cervix may prevent 
dilatation and make necessary the use of the knife. 

If the child is alive and viable hysterotomy becomes an alternative to 
the abdominal Caesarean section, and if conditions are favorable the latter 
is always to be preferred. 

Centra-indications. — The operation is, of course, contra-indicated in 
cases of marked pelvic contraction and when the child is dead. If the 



566 OBSTETRIC SURGERY 

patient is a primipara, with small vagina and vulval orifice, extensive 
laceration is hardly avoidable, and if conditions are favorable abdominal 
Csesarean section is again to be preferred. The same statement is true of 
cases in which the patient is over-time and the child presumably over-large. 
In a general way, too, one may say, and this is very important, that it 
is contra-indicated whenever the slower methods will suffice. 

Cervical Incisions 

Deep incisions of the cer^'ix, otherwise known as Diihrssen's incisions, 
are still practised by some operators. These incisions are only made after 
the cervical canal has been obliterated. They extend to the cervico- 
vaginal junction and no further. After delivery the resulting wounds are 
sutured. These incisions are now superfluous. ^Moreover, they are not 
free from serious risk, since during the subsequent delivery the incisions 
may extend indefinitely by tearing. The condition is much like that which 
obtains in a hysterotomy in which the incision has been too short. 

To Sum Up. — Before the cervix will admit, or can easily be made to 
admit the finger, or in other words, before the last three or four weeks 
of pregnancy, the cervicovaginal tampon is by all odds the safest and best 
method of securing dilatation. The technic is given in connection with the 
induction of abortion to be presently described. 

After this time Voorhees's modification of the de Ribes bag is to be 
preferred. 

Manual dilatation finds its best field in cases that have already been 
partly dilated, and whenever practicable should be reserved for such cases. 
It is often necessary preliminary to the forceps operation and to version. 

Hysterotomy should be reserved for cases in which a delay of a few 
hours plainly involves serious danger. 

If the use of the steel dilators becomes necessary, the graduated dilators 
are to be preferred to those of the glove stretcher variety. 



CHAPTER XXA'I 

THE INDUCTION OF ABORTION AND OF PREMATURE 

LABOR 

IxDUCTiox OF Abortion. Indications. Technic of Induction Dur- 
ing THE First Three ]vIonths. Technic of Induction During 
Second Three Months. The Induction of Premature Labor. 
Indications. Different Methods, with the Technic of Each. 
The ^Iethod of Krause. The Tampon. The Rubber Bags. 
]\Ianual Dilatation 

By the induction of abortion is meant the artificial interruption of 
pregnancy during the first twenty-eight weeks ; i.e., before the foetus 
becomes ^-iable. The artificial interruption of pregnancy at any subsequent 
period is known as the induction of labor. 

Indications for the Induction of Abortion 

]\Iost physicians believe that the induction of abortion is indicated if it 
appears certain that the continuance of pregnancy will destroy, or seriously 
imperil, the life of the patient. If we could always be sure that the con- 
tinuance of pregnancy would have this effect, the problem would be easier; 
but since certainty is not always attainable, difficult questions will continue 
to arise. The conditions which may bring about such a state of affairs 
are considered elsewhere, and it is only necessary to summarize them 
here. Among the most common are pernicious vomiting, incipient tuber- 
culosis in early pregnancy, pernicious anaemia and leucocythsemia, cardiac 
disease with beginning failure of compensation, and chorea. 

Examples of local conditions are placenta praevia, mole pregnancy, 
and death of the foetus, with decomposition of the uterine contents. Retro- 
flexion of the gravid uterus with incarceration, formerly considered a posi- 
tive indication, may, if the circumstances are favorable, be treated by 
laparotomy. 

Eclampsia, or threatened eclampsia, seldom constitutes an indication 
for the induction of abortion, but it often justifies the induction of labor. 
On the other hand, true nephritis complicating early pregnancy may well 
give rise to serious thought. 

Indications for the Induction of Labor 

These are the same as those for the induction of abortion with some 
additions. Eclampsia and placenta prsevia figure much oftener as indi- 
cations, after the period of viability has been reached, than before. When 
there is a history of large children and difficult labors, the induction of 
labor two or three weeks before term may be not only justified, but im- 

567 



568 OBSTETRIC SURGERY 

peratively indicated, and the same thing is true of cases of habitual death 
of the foetus. ^Many still practise the induction of labor in cases of 
moderate pelvic contraction, though with the gradual improvement in the 
results of the Csesarean section there is less reason for this now than 
formerly. Acute hydramnion is a rare but unmistakable indication for the 
induction of labor. 

It would carry us far beyond our limits to consider every condition 
that might possibly justify the induction of labor. In general, however, 
it may be said that there is at present a tendency to induce labor rather 
more frequently than occasion demands. Xot all the ills that beset a preg- 
nant woman can be cured by the induction of labor. In some cases, e.g., 
in advanced tuberculosis, and in cardiac cases that are doing well, the 
results may be immediately disastrous. 

Technic of the Induction of Abortion During the First 
Three AIonths 

Certain operators pride themselves upon being able to complete the 
induction of abortion at one sitting, by rapidly and forcibly dilating the 
cervix with branched dilators, breaking up the uterine contents, and empty- 
ing the uterus with the curette. All this is done, of course, at the expense 
of the maternal structures. I have heard this called " the surgical method." 
Correctly speaking, it is a very unsurgical method. Some of the worst 
tears of the cervix that I have ever seen, tears far worse than those ordi- 
narily produced in labor, and even in forceps operations and versions of 
average difficulty, have been produced in this way. It is self-evident that 
an approach to normal conditions, as far as an abortion can be said to 
present normal conditions, should be sought. In other words, that cervical 
dilatation should be gradual, and should be preceded and accompanied 
by softening and obliteration of the canal. This is best accomplished by 
certain preliminary measures which I shall now describe. 

The operation should always be performed in a hospital if possible. 
This tends to avoid any impression of secrecy and conduces to careful, 
deliberate and aseptic work. 

Asepsis should be rigorous and the rules already given in the chapter 
on obstetric operations carried out to the letter. In addition to this, the 
vagina should be thoroughly scrubbed out with sponges of sterilized cotton 
soaked in a 2 per cent, lysol solution. Rubber gloves should be worn. 
When a physician takes upon himself the serious responsibility of inducing 
abortion, he also becomes responsible for the aseptic conduct of the case. 
Moreover, it has always seemed to me that in this unphysiological process, 
nature is not able to surround our patients with the natural safeguards 
that are part of the physiological process of labor. With scrupulous care, 
however, there is little or no danger. 

Ether or ether-oxygen should be the anaesthetic. There are no factors 
in these cases making for increased safety in chloroform anaesthesia. A 



ABORTIOX AXD PREAIATURE LABOR 



569 



lingering idea that such factors exist in the induction of abortion, as they 
undoubtedly do in purely obstetrical operations, has been responsible for 
an occasional death that might have been prevented. 

\Mth the patient upon the table and in the lithotomy position a careful 
bimanual examination is made in order to exclude extra-uterine pregnancy, 
or an acute inflammatory process in the parametrium, and to determine 
accurately the position of the uterus. This precaution, too often neglected, 
is nevertheless highly important. To overlook an extra-uterine pregnancy 
or a tubal abscess might prove a fatal mistake, and if the operator does not 
know the position of the uterus, he will not know how his instruments 
should be curved, or in what direction they should be passed. A careless 
operator who overlooks a retroversion may easily perforate the uterine wall. 

The cervix is now seized and fixed with a tenaculum. A weighted 




Fig. 339. — Method of using the placental forceps. 

speculum is a convenience, but not a necessity. Strong traction is not 
necessary and may do harm. If the cervix is closed it should be dilated 
by the insertion of tw^o or three of the smaller sizes of the graduated dila- 
tors of Hanks or Hegar. Just enough dilatation for the insertion of a 
few strands of gauze is the object sought. The branched dilators so 
commonly used are not suited to this work, and in careless or inexperienced 
hands are highly dangerous. Dilatation should be slow, gradual, and 
uniform, and time should be allowed for cervical relaxation. It is not 
necessary to puncture or break up the ovum, but if this should happen no 
great harm is done. Cervix and vagina are now tightly packed with gauze 
and a T-bandage applied. The tampon is allowed to remain from twelve 
to eighteen hours. At the end of this time the cervix will usually have 
become softened and dilated to the extent of admitting the finger, by means 
of which the operator removes the bulk of the uterine contents, and deter- 
mines that the uterus is empty. 



570 OBSTETRIC SURGERY 

The subsequent treatment of the case is that of incomplete abortion 
and has already been given. The bulk of the ovum should always be 
removed with the finger if possible. If pregnancy is of less than three 
months' duration, curettage should be performed. A single douche of hot 
salt solution helps contraction, limits hemorrhage, and washes out frag- 
ments that may have been left. It is not absolutely necessary, however. 

Now and then one meets a case in which the cervix admits the finger, 
but the canal is still preserved, and the finger can reach, but not grasp, the 
uterine contents. Here the experienced operator can usually succeed with 
the placental forceps and blunt curette (Fig. 339) . The beginner, however, 
will do well to repeat the tampon, this time tightly packing the cavity of 
the uterus and thus insuring the easy removal of its contents twelve hours 
later. 

It is well to use mildly iodized gauze for the second tampon. 

Techxic During the Second Three Months 

During the fourth, fifth and sixth months the tampon is still the best 
agent for provoking uterine contractions and bringing about dilatation of 
the cervix. The rubber bags, so useful in the latter weeks of pregnancy, 
do not work well here. Considerable dilatation with steel instruments 
may be necessary to permit the introduction of even the smallest size. 
The long and hard cervix dilates slowly, the process may last for days, 
and the successive introduction of larger sizes, with the attendant manipu- 
lations, discourages the patient and predisposes to infection. 

There is little likelihood of the delivery of an intact ovum at this time, 
and it is well before introducing the tampon to rupture the membranes 
with a sound and allow the amniotic fluid to drain away. This, in itself, 
ushers in uterine contractions and markedly assists the action of the 
tampon. Indeed, if there is no special reason for haste the rupture of the 
membrane is usually all that is necessary. 

The subsequent progress of the case closely resembles premature labor 
and calls for no special comment. 

Induction of Premature Labor 

After the child becomes viable, i.e., after the beginning of the seventh 
month, two lives are to be considered. As a general rule, rupture of the 
membranes is to be carefully avoided, since it distinctly increases the risk 
to the child. This is especially true in the case of a primipara with long 
and hard cervdx. There is also a slightly increased risk to the mother, 
owing to the fact that the first stage is usually prolonged, and decomposi- 
tion of the uterine contents more probable. The artificial rupture of the 
membranes is, however, the ideal method in certain cases, e.g., in hydram- 
nion, and twin-pregnancy, q.v. It is also of great value as an auxiliary 
to other methods, or as a substitute for them in case of their failure. 



ABORTION AXD PREMATURE LABOR 



571 



THE METHOD OF KRAUSE 

A time-honored and still popular method is that of Krause, which con- 
sists of the introduction of a No. 17 Fr. bougie, or of a rubber catheter 
of similar size, between the ovum and the uterine wall. The presence of the 
foreign body excites uterine contractions. If a catheter is used it is intro- 
duced by means of the contained stylet, which is withdrawn later. 

Technic— With the patient in the lithotomy position the cervix is 
exposed by broad specula and the anterior lip fixed by two volsella, which 
are entrusted to an assistant. The operator now passes his finger between 
the cer^'ix and the anterior uterine wall and separates the membranes as 
hig^h as he can convenientlv reach. This facilitates the entrance of the 
bougie, and lessens the danger of rupture of the membranes (Fig. 340). 




Fig. 340. — Introduction of the bougie. 

Two fingers of the left hand are now passed up into the area of separa- 
tion, and between the two fingers as a guide the bougie is passed cautiously 
upward until but a few inches are left, protruding from the cervix. It 
is better to pass it anteriorly, since otherwise it may be arrested by the 
promontory of the sacrum. This is especially true when labor is induced 
on account of pelvic contraction. Then, too, the placenta is usually located 
upon the posterior wall. Should resistance be encountered, it is likely that 
the point of the bougie is impinging upon the placenta, and in this case it 
should be withdrawn and reentered at another point. When the bougie is 
in place the vagina is lightly packed with gauze. If the membranes are 
ruptured the bougie is no longer necessary and should be removed. If 
hemorrhage occurs, the cervix and vagina should be packed with gauze. 



572 OBSTETRIC SURGERY 

If there are no contractions in from 12 to 24 hours another bougie may be 
inserted alongside the first. 

This method is perhaps the easiest, and in many cases gives good 
results, but it has certain disadvantages. 

In the first place, it is very uncertain in its action. Hours, and even 
days, may elapse before uterine contractions are excited, and in some cases 
they are not evoked at all. 

In the second place, there is considerable danger of rupture of" the 
membranes ; this accident has happened many times to men of experience. 

The third and most serious objection is the danger of infection, which 
in my opinion is greater in this than in other methods of inducing labor. 
This has also been the experience of many others, including the authorities 
of the great Rotunda Hospital in Dublin. It is quite true that this danger 
may be much diminished by careful technic, but there are certain dangers 
that are inherent in the operation itself. It is difficult or impossible to 
sterilize the bougie, and there is the additional danger involved in passing 
it through the vulva and vagina, which are not sterile, up to the placental 
site, the most vulnerable point in the birth canal. 

THE TAMPOX IX THE IXDUCTIOX OF LABOR 

Even after the period of viability has been reached, the tampon remains 
the safest and best agent for bringing about dilatation of the cervnx up 
to the time when the latter will admit, or can easily be made to admit, the 
finger. After one or two fingers are admitted, a A'oorhees bag is inserted. 

THE RUBBER BAG IX THE IXDUCTIOX OF LABOR 

AMien, however, the finger can be passed through the cervix with no 
great difficulty, i.e., approximately four to six weeks before term, the bags 
are safe, convenient, and effectual, and the tampon quite unnecessary. 
The technic of their use has already been given. 

Some writers advocate the use of the bags in the sixth, seventh and 
eighth months, while the canal of the cervix is still preserved and undilated. 
This involves a preliminary dilatation by steel dilators and the risk of a 
bad tear, especially if the branched dilators are used. In my opinion it is 
seldom necessary. 

The inexperienced obstetrician, and the man whose training has been 
chiefly surgical, is prone to find occasion for grave operations in con- 
ditions which the practised accoucheur successfully combats by milder 
methods. There are few cases in which the delay required for conservative 
measures involves as much risk as does the additional burden of a rapid 
operative delivery. 

No matter what method of inducing labor is chosen, it is well, when- 
ever time permits, to give an ounce of castor oil the night before beginning 
the operation. In many cases this will prove to be all that is necessary. 
There is something almost specific in the efifect of castor oil in these cases. 



ABORTIOX AXD PREMATURE LABOR 573 

This fact, well known to the monthly nurse, has apparently been over- 
looked by many teachers and writers upon obstetrics. Its effect is most 
marked in the latter weeks, and becomes greater as the period of labor 
approaches. In many cases, if a patient receives an ounce of castor oil 
at night, labor pains begin the next morning. It is therefore wise to 
precede the induction of labor by the administration of castor oil. Of 
course the converse of this is also true. Castor oil should never be given 
to a' pregnant woman unless it is intended for some legitimate reason to 
induce labor. 

Another drug which aids very materially in the induction of labor is 
pituitrin. There are many cases in which, after preliminary dilatation of 
the cervix by the bag or tampon, and after some progress has been made, 
the contractions are slow and inefficient and the labor bids fair to be long 
delayed. In these cases pituitrin is often of great value in hastening the 
process. The contra-indications to its use are given elsewhere. 

^lanual dilatation is not in itself a method of inducing labor, but it is 
sometimes most valuable in accelerating the progress of labor. For exam- 
ple, when by the use of the rubber bags or by some other method the 
canal of the cervix has been made to disappear, and the external os has 
become dilated to the extent of admitting three fingers, the process may 
be hastened, or indeed rapidly completed, by simply stretching the cervix 
with the fingers of one hand and then rupturing the membranes. 

The operator should not think that his task is over when once he has 
succeeded in starting the " machinery " of labor. He who induces labor 
before term is under a peculiar obligation to look carefully after the welfare 
of the foetus. He should on no account neglect the careful auscultation of 
the fetal heart. He should not allow himself to forget that the power of 
resistance of these premature children is less than normal, and that it is not 
well in these cases to permit the second stage of labor to continue too long. 
If operative delivery becomes necessary he should remember that, as we 
shall see in the next chapter, the forceps are usuallv safer in these cases 
than version, and that by the use of Kristeller's method we may even be 
enabled to dispense with operative delivery altogether. 



CHAPTER XXVII 
THE FORCEPS 

Definition. — The obstetrical forceps is an instrument by means of 
which traction is made upon the fetal head for the purpose of effecting or 
hastening delivery. 

Historical. — The story of the Chamberlen family, Englishmen of 
French descent, of how they invented a crude, but fairly effective, short, 
straight forceps, how they kept their secret for a hundred years, and 
how their invention finally became public, is familiar to every student of 
obstetrics. It is an unsavory history, dealing as it does with those who, 
like the quacks of to-day, would capitalize the sufferings of their fellow- 
men ; relieved by the story of the philanthropic Hollanders, Vischer and 
Van der Poll, who gave away what information they had been able to 
purchase about the new instrument, and of the eloquent Frenchman, 
De La Alotte, who denounced with biting words those who would keep such 
a secret for money. 

The original forceps of the Chamberlens was a simple straight forceps, 
crude in construction but, nevertheless, embodying the mechanical prin- 
ciples of the forceps of to-day. It had but one curve, the cephalic, and 
hence was adapted only to cases in which the head is low in the pelvis. 
With the passing of the years the instrument of Chamberlen became 
modified. Smellie, in England, and Levret, in France, made it longer and 
added a second curv^e, designed to correspond with the axis of the pelvic 
canal. In France, owing to the teaching of the Church, which emphasized 
the value of fetal life, the forceps were devised for use at or above the 
pelvic brim, and were, therefore, longer and stronger and had a more 
pronounced pelvic curve than those used in England and Germany, where 
version was usually preferred. To some extent this difference continues 
until the present day. Both forms have survived as they deserved. One 
for the high, and the other for the low, operation. 

In 1877 the master mind of Tarnier perfected the axis-traction forceps, 
and in his latest model we have, I believe, the perfection of forceps 
construction. 

Construction. — Handles are of various patterns, the essential features, 
common to all, being the lateral projections at their junction with the lock. 
These projections are indispensable for traction. The three varieties of 
lock are the English, French and German. The English lock is easy of 
adjustment, simple in construction, and is to be preferred in easy opera- 
tions with the ordinary forceps. The French lock, which requires a separate 
screw, Is somewhat more complicated, but is indispensable in difficult cases 
when the Tarnier forceps are used, since it holds blades and head solidly 
574 



THE FORCEPS 



575 



together, making them, as it were, of one piece. The German lock is an 
attempt to combine the advantages of both. 

The shanks may be separated, the separation beginning at the handles, 
as in the Simpson and Tamier forceps, or they may be superimposed, as 
in most other models. In the latter case the instrument has more com- 
pressive power and is. at least in careless or unskilled hands, more danger- 
ous to the foetus. The shanks may be long or short. In the short forceps 





Hodge 



Simpson 
Fig. 341. — Hodge, Simpson, and Davis forceps. 



Davis 



there may be hardly any shanks at all, the pelvic curve beginning almost 
at the lock. In other cases the shanks are long, the pelvic curve beginning 
at some distance from the handles. The latter plan is preferable, since the 
longer instrument has more power and leverage, and can be used with 
much more delicacy of manipulation. It is a gross error to suppose that an 
instrument is less likely to do harm because it is short and weak. The 
blades may be wide, as in the Hodge or Davis forceps (Fig. 341), or 
narrow, as in most other models. The latter plan is preferable. The wide 
blades were intended to embrace the parietal eminences. The increased 



576 OBSTETRIC SURGERY 

width is unnecessary and makes the introduction of the blades more 
difficuk. This is especially true of the introduction of the second blade. 

The blades may be fenestrated, as in most models, or solid, as in those 
of Ohlshausen and ]\IcLane. Solid blades are easy of introduction, rota- 
tion, and withdrawal, but so much compression is required to prevent them 
from slipping that the danger to the child is much increased (Fig. 342). 

The forceps blade has two curves : the curve " on the flat," or cephalic 
curve, and the curve '' on the side," or pelvic curv-e. In my opinion, there 
is never any necessity for a marked cephalic curv^e, and such a curve is 
always a bad feature. No blade can have a pelvic curve which is adapted 
to both the high and the low operation. For the low operation a very 
moderate pelvic curve is best. Indeed, the straight forceps formerly used 
is much better suited to this operation than an instrument with a marked 
pelvic curve. 

The *' Properties " of the Forceps. — The older writers were accus- 
tomed to speak in quaint fashion of certain " properties," or " functions," 
of the forceps. These " properties " are traction, compression, leverage, 




Fig. 342. — Tucker-McLane forceps. 

and dynamic action ; to which we have recently added rotation. Traction, 
of course, is the chief function of the forceps. In the light of modern 
teaching compression is to be considered as incidental and unavoidable. 
The forceps is not to be used as a cephalotribe. The forceps is seldom used 
as a lever. One of the very rare instances of such use is in the so-called 
pendulum tractions to be described later. In some cases the mere presence 
of the forceps blades in the uterus excites contraction. This is known as 
the dynamic property of the forceps. Contractions occur with some 
evidence of progress before the first traction is made. The assistance thus 
afforded by nature is welcome when it comes, but unfortunately it cannot 
be relied upon. Rotation is best illustrated in the treatment of occiput- 
posterior cases, which will be presently discussed. 

Varieties. — There have been many modifications of the forceps. To 
describe and reproduce them all would be a profitless task. Most of them 
are of interest from an historical standpoint only. The description of a 
few typical forms will sufiice. 

Let us begin with the ordinary instrument ; the instrument suited to the 
low operation. The accompanying illustrations show some types in com- 
mon use. Most generally employed, perhaps, is the Simpson forceps, bom 



THE FORCEPS 577 

in Scotland, but very generally used throughout Great Britain and the 
British colonies, as well as in the United States and in Vienna. It is an 
excellent instrument for easy cases. The pelvic curve is very moderate, 
as it should be in an instrument designed for the low operation. The 
shanks are not superimposed but separated, the separation beginning at the 
lock. This is an important feature of the Simpson forceps, diminishing 
as it does the danger of compression and thus greatly lessening the risk to 




Fig. 343. — -The Nasgele forceps. 

the foetus, especially in the hands of the careless or inexperienced operator. 

The X^egele forceps, much used in Germany, has the German lock 
already described. Its pelvic curv-e is too great for the low operation and 
its length insufficient for cases in which the head is at the brim of the 
pelvis (Fig. 343). 

The Elliott forceps (Fig. 344). a favorite in New York and vicinity, 
a rather light instrument with superimposed shanks and moderate pelvic 




FIG. 344-— The Elliott forceps. 

curv^e, is convenient and efficient in easy cases, but should be used with 
some care, as it compresses the head more than the Simpson model. The 
same caution applies with even greater force to the solid blade forceps 
already mentioned. The earlier models of the Elliott forceps had a very 
moderate pelvic curve and are much preferable to those now in use. The 
latter represent an attempt to construct an instrument suitable for both 
the high and low operations. Such attempts are always unsuccessful. 

Choice of Instrument 

It is an absurdity to ask which is the best forceps. There is no forceps 
which is " best " for all purposes. In the high forceps operation, for 
example, a somewhat marked pelvic curve is a necessity. This cur^^e, 
becomes less necessary as the head descends in the pelvic canal. At the, 

37 



578 



OBSTETRIC SURGERY 



outlet it is a positive disadvantage, the handles often touching the mother's 
abdomen and the shanks coming into contact with the tissues in the neigh- 
borhood of the anterior commissure, during the raising of the handles 
which accompanies the final extension of the head. On the contrary, the 
ordinary^ forceps with a slight pelvic curve are entirely inefficient in the 
high operation, and many such operations have failed because of an inade- 
quate instrument. Then, too, in the case of a primipara with a very small 
outlet and the head resting on the perineum, it is hardly fair to the patient 
to use the somewhat heavier blades of the Tarnier instrument (Fig. 345). 
Finally, it is sometimes an advantage to substitute one instrument for 
another in the course of an operation. For it is an undoubted fact, 
as I have repeatedly demonstrated, that in some cases after the head has 
been brought well down to the floor of the pelvis by the Tarnier instru- 
ment, extraction can be much more easily performed by exchanging the 
latter instrument for one with a slight pelvic curve. 




Fig. 345. — Tarnier axis-traction forceps. 

I am accustomed to say to my students that every man who intends to 
do much obstetric work should have two pairs of forceps, an axis-traction 
model for use in high and median operations, and a Simpson or Elliott 
forceps for use in those cases in which the head has reached the pelvic floor. 

Indications. — It would be a useless task to tr\r to enumerate every 
possible condition or circumstance that might call for the use of the 
forceps. In a general way they may be grouped under two heads. Those 
which relate to the mother, and those which relate to the child. Now and 
then we have urgent indication in the general condition of the mother, 
e.g., pulmonary oedema, eclampsia, marked exhaustion, antepartum infec- 
tion, cardiac and pulmonary diseases, in a word, cases in which the con- 
tinuance of labor directly threatens the life of the mother. In these the 
indication is clear. The majority of forceps operations, however, are not 
of this character. They are designed to prevent exhaustion, and to cut 
short the sufiferings of the patient. 



THE FORCEPS 579 

Here the problem is more difficult. One does not wish to interfere too 
soon, but to wait until signs of exhaustion are well marked is to wait too 
long. The causes of delayed labor are considered elsewhere. Among 
those that most often make necessary the use of the forceps are posterior 
positions of the occiput and rigidity of the perineum in elderly primiparse. 
/ Jiave frequently found the cause in unusual size of the fetal head. Stout 
zi'onien seem to require operative assistance oftener than others. Moder- 
ate contraction of the pelvis may have passed unrecognized. 

The obstetric teacher is often asked " How long should one wait before 
applying the forceps? " As a matter of fact, no exact time limit can be 
given. It is not so much a matter of time, as of the condition of mother 
or child. Perhaps we might say, in a general way, that after two hours 
of good labor pains in the second stage, or from two and one-half to 
three hours in the first stage without progress, interference is indicated, 
but the experienced accoucheur is bound by no such rules. If progress is 
present, suffering not too severe, and child in good condition, he might 
wait longer. 

On the other hand, if sufTering is excessive he might interfere sooner. 
Of course, if the head is low in the pelvis one is justified in interfering 
somewhat earlier than one would if the head were higher, since interfer- 
ence is attended with less danger to the mother. This is especially true 
of the inexperienced operator. Likewise the child is more endangered 
by waiting after rupture of the membrane. 

The caput succedaneum affords a fairly reliable index of the pressure 
to which the head is being subjected. When a complete arrest of progress 
is accompanied by a large and increasing caput succedaneum there is little 
chance that nature will prove equal to the task. 

In my experience considerable importance is to be attached to the 
statements of the patient if she be a woman of intelligence and fortitude, 
and especially if her physician has attended her in previous labors. When 
such a patient complains that she " can bear it no longer," that the pains 
are not helping her, etc., her statements should receive serious considera- 
tion. Such cases must, of course, be distinguished from those of neurotic 
and hysterical patients, who can usually be quieted by chloral. 

The older writers taught, and one sometimes hears even now, that one 
should wait until there is a steady rise in the maternal pulse, but to wait 
for this is obviously to wait too long. It should be the aim of the obste- 
trician to learn to recognize the necessity for interference before the signs 
of exhaustion are present and unmistakable. 

Indications from the Side of the Foetus. — In considering the indi- 
cations for the use of the forceps, far too little attention is usually paid to 
the foetus. It is not too much to say that the most important part of a low 
forceps operation is the auscultation of the fetal heart. The first symptom 
of impending asphyxia of the foetus is a diminution in the fetal heart-rate. 
As we have already seen, the fetal heart beats more slowly during a con- 



580 OBSTETRIC SURGERY 

traction, but normally resumes its usual rate when the contraction is over. 
If a heart which has been beating at the rate of from 130 to 160 beats loses 
20 or 30 beats, and if this decreased rate is maintained between the con- 
tractions, a most careful watch should be maintained. A fetal heart-rate 
in the neighborhood of 100 is an indication for delivery, if this can be 
accomplished with no great risk to the mother. 

The passage of meconium is often, but not always, an indication of 
asphyxia and should always lead, if not to the application of the forceps, 
at least to a most careful auscultation of the fetal heart. 

From this it follows that during the second stage of labor the forceps 
should be at hand, sterilized and ready for use. It is not necessary to 
employ the instrument because it is ready, but it is a great misfortune 
not to have it at hand when it is imperatively needed. 

Choice Between Forceps and Version 

In most cases of delayed labor the choice lies between forceps and 
version. A study of the indications for the forceps operation then is 
necessarily incomplete, unless it includes something about the choice 
between these two procedures. 

In the first place, it is to be remembered that failure with the forceps 
does not preclude the subsequent performance of version, while a version 
half completed must be finished at any cost. When the head is above the 
brim and cannot be made to engage, version is undoubtedly safer than 
a persistent attempt with the forceps. 

In cases of malpresentation at the pelvic brim, e.g., face, brow, or 
posterior occiput, version is preferable. 

In the case of a premature child the forceps are usually to be pre- 
ferred, since owing to the small size of the head delivery is easy, whereas 
these feeble infants are easily affected by the necessarily rough manipula- 
tions of version. 

In the case of a primipara, forceps delivery, other things being equal, 
is preferable as being less likely to result in severe laceration of the soft 
parts. With the forceps the advance may be intermittent and gradual, 
but in version the after-coming head must be delivered rapidly if we are 
to save the life of the child. 

In a general way the forceps operation is safer for the child than 
version. Even in easy versions the unavoidable handling of the cord, and 
the admission of air into the uterus may result in premature fetal inspira- 
tions with resulting asphyxia. 

Version should not be undertaken when there is any considerable 
narrowing of the transverse diameter of the pelvic brim, since the long 
axis of the head is thus brought into coincidence with the shortened 
transverse diameter of the pelvis. 

Finally, when to interfere cannot be learned altogether from text- 
books. The observant physician can tell much from the demeanor and 



THE FORCEPS 581 

attitude of the patient, and the character of the pains. He must accustom 
himself to long hours of watching at the bedside. He cannot begin this 
too early. It is the only way in which he can become possessed of that 
unwritten and unconscious knowledge that is born only of experience 
and that seldom fails to recognize efforts that are fruitless, and suffering 
that should no longer be borne. H not willing to make this sacrifice for 
the good of his patients, he had better choose a less trying calling. 

Prognosis. — There should be no direct mortality in the forceps opera- 
tion, when performed upon a patient in good condition, by an operator 
of experience and judgment who knows how to recognize conditions that 
contra-indicate the operation, or forbid its continuance. 

On the other hand, when the operation is unskilfully conducted, e.g., 
when the instrument is applied without an accurate diagnosis of position 
and presentation, when persistent efforts are made to overcome obstacles 
by brute force, when the forceps are applied through a half-dilated cervix, 
or when the narcosis is unduly profound and prolonged, the danger to 
life is considerable, and more or less subsequent disability very probable. 
The particular dangers incident to these and other blunders are considered 
elsewhere. Severe laceration of the cervix, attended by hemorrhage and 
shock, is the complication that it has most often been my lot to witness. 

The danger of infection is, of course, somewhat greater than in normal 
delivery, but with proper precautions this danger becomes almost negligible. 

It is usually stated that the low operation is practically without danger, 
that the median operation is a little greater risk, and that the high 
operation is the most dangerous of all. In a general way this is true, but 
in practice one meets with many exceptions, e.g., if the head is not large, 
and other circumstances are favorable, the high operation may be surpris- 
ingly easy, while if the head is very large the median operation may tax 
the resources of the elect. 

There is not the slightest doubt that the fetal mortality is somewhat 
higher when the forceps are used than in labor strictly normal. Exact 
statistics are not available. Much of the mortality is due to improper 
technic. On the other hand, however, the timely and skilful use of the 
forceps often results in the saving of fetal life. Experience long ago con- 
vinced me that better results are obtained when the axis-traction instrument 
is employed. 

Conditions Which Justify the Application of the Forceps 

A presentation of the head, or, rarely, of the breech. A living child. 
A pelvis without marked contraction. The head should not be hydro- 
cephalic or too large for the pelvis. The latter point is difficult to deter- 
mine. It is hardly necessary to tell any sane man that the membranes 
should have ruptured, but many very intelligent practitioners do not seem 
to know that the cervix should be fully dilated. This leads to the considera- 
tion of an important subject which requires separate consideration, viz. : 



582 OBSTETRIC SURGERY 



PRELIMINARY DILATATION OF THE CERVIX 

The forceps are not to be applied until the cervix is completely dilated. 
The custom formerly taught and unfortunately still practised by many, of 
applying the forceps through a half-dilated cervix and using the head 
as a dilator, should be unreservedly condemned. It has often resulted 
in bad tears of the cerv'ix, with severe hemorrhage and subsequent inva- 
lidism. In other cases the operator has not been able to complete the 
operation at all. 

When the application of the forceps is indicated, and the cervix is 
but partially dilated, dilatation should be completed manually by the 
method already described. It is then usually easy to push the head well 
down into the cavity of the pelvis by external pressure, and the operation 
is thus made much easier than would otherwise have been the case. 

To tell the student that cervacal dilatation is a necessary condition of 
the forceps operation, and not to tell him at the same time that if the 
cervix is not dilated he himself must accomplish the dilatation, is to leave 
him utterly in the dark. In many of the cases in which dilatation is most 
urgently indicated it will never be accomplished by the unaided efforts 
of nature. 

Classification. — Broadly speaking, forceps operations are of three 
kinds, high, low and median. 

When the greatest diameter of the head is still above the brim, the 
operation is known as the high operation. 

When the above diameter has passed the brim, but rotation has not 
occurred, the head remaining transverse or oblique in the pelvic cavity, the 
operation is known as median. 

When the head is well down upon the pelvic floor and the occiput 
has rotated or almost rotated under the pubic arch, the operation is called 
low. We must remember, however, that in some cases the occiput does 
not rotate until the very moment of emergence. 

In cases in which the head is floating above the brim and cannot be 
made to engage after the membranes have been ruptured and the cervix 
dilated, the forceps are usually contra-indicated. 

General Considerations. — The mechanics of the forceps operation are 
somewhat confusing at first, and it is well for the beginner to fix firmly in 
his mind a few general rules zcJiich are absolutely indispensable. It is my 
obervation that those who do not learn these rules at the beginning do not 
learn them at all, and never become proficient operators. Let the beginner 
learn them here and now. 

In all cases in which the head occupies the right oblique diameter or 
when it is transverse with the occiput pointing toward the left, the left or 
lower blade is applied first. These cases, since they include the more 
common L. O. A. and R. O. P. positions, as well as all low cases, constitute 
the great majority (Figs. 346 and 347). 



THE FORCEPS 



583 



/. 



L O A 
ROP 
LOT 




Fig. 346. — Forceps held as they would be applied in the above positions. 





y ' 






i^OA 




; . ^ 


LOP 

ROT 


, 




4^ 


\ 




*^^L 


i^r^ 




--^^ 


3' "": 






i 



Fig. 347. — Forceps held as they would be applied in the above positions. 



584 OBSTETRIC SURGERY 

When, however, the head occupies the left obHque diameter, i.e., when 
it is in the less common R. O. A. or L. O. P. positions, the right or lower 
blade, which is held in the right hand and which is passed into the right 
side of the pelvis, is introduced first. The latter fact, which will presently 
be illustrated and explained, should constantly be kept in mxind. 

Except in high cases and when the head occupies the transverse diame- 
ter of the pelvis, the forceps are to be applied, if possible, to the sides of 
the head and not with reference to the sides of the pelvis. 

Technic. — I am accustomed to teach that all forceps operations should 
be performed upon a table. A low table is preferable, because of the 
upvv^ard traction that must be made during the stage of expulsion. It is 
true that the cross-bed position suffices for easy operations, but one cannot 
always be sure that a given operation will be easy. Even the experienced 
accoucheur is occasionally deceived. There are many sources of error. It 
is often difficult or impossible to recognize unusual size of the head. A 
large head with a pronounced caput may be found to be considerably 
higher than was supposed, a posterior position of the occiput may have 
been overlooked, a slight pelvic deformity may have passed unnoticed, and 
so on. Even if the operation is not difficult it may be necessary later to 
pack the uterus for hemorrhage, or to repair cerv'ix or perineum. These 
operations as well as the forceps operation cannot be properly done with 
the patient in bed. 

This operation, in view of the frequency with which it is performed and 
the fact that two lives are at stake, is perhaps the most important operation 
in all surgery. It is the height of folly to undertake such an operation, 
except under favorable circumstances, or at least under circumstances that 
are as favorable as they can be made. The general technic has already 
been considered. Two features are well worth repetition. The importance 
of strictly limiting the amount of the ansesthetic, and of emptying the 
bladder as a final preliminary measure. A rupture of the bladder is an 
unpleasant complication of the lying-in period. Xow and then the obstetric 
consultant is called to a case in which the sole cause of delay is a dis- 
tended bladder, the use of the catheter making the forceps operation 
unnecessary. 

Posture of the Patient. — Some operators, especially in Great Britain, 
prefer to apply forceps with the patient in the lateral position. In 
my opinion the dorsal position is preferable, since asepsis is more easily 
maintained. The patient, however, may, if desirable, be placed in this 
position during the operation. In some cases of high arrest, in which 
the Tarnier instrument is used, traction in the axis of the brim may be 
more conveniently and efficaciously made with the patient in the Sims 
position. 

Anaesthesia. — The administration of anaesthetics in forceps cases is an 
art to be acquired and is quite different from anaesthesia in general sur- 
gery. It deserves and will repay much study. As we have already seen, 



THE FORCEPS 585 

too much of the aiicTsthetic is usually given in obstetric operations and this 
is especially true of the forceps operation. Here there is no necessity, as, 
for instance, in version, for profound narcosis and complete relaxation. 
Indeed, the reflex response of the uterine muscle and the help of half 
voluntar}^ efforts of the patient are often of great assistance. It is, there- 
fore, in most cases, an advantage to withhold the anaesthetic for a time 
in order to see what the uterus can accomplish, unaided or assisted by 
pressure upon the fundus, without, as a rule, removing the forceps. 

In easy cases, the most important part of the operation is the securing 
of a correct application, and for this complete anaesthesia is usually neces- 
sary, but not necessary or even desirable to keep the patient profoundly 
narcotized during the subsequent course of the operation. The danger of 
hemorrhage and of fetal narcosis are minimized by strictly limiting the 
amount given. Between tractions primary anaesthesia is all that is necessary. 
As soon as the head is delivered the anaesthetic should be discontinued. 

What anaesthetic shall be used? In making a selection the physician 
will do well not to disregard the question of the comparative safety, both 
to mother and foetus, of the anaesthetics in general use, especially in pro- 
longed operations and in cases of threatened or actual hemorrhage, not 
forgetting that for primary anaesthesia ether is the much safer agent in 
the hands of a nurse or bystander. 

Personally I prefer ether, given by the drop method, in practically all 
cases. The danger of postpartum hemorrhage after chloroform anaesthesia 
is a very real one, even in short operations, and should always be borne in 
mind. In such cases ergot should be given as a routine practice and the 
patient should be carefully watched for not less than two hours. 

If it becomes necessary to give an anaesthetic after delivery, for instance 
in the case of perineorrhaphy or manual removal of the placenta, ether or 
nitrous oxide-oxygen should always be preferred to chloroform. 

Final Examination. — A final examination for purposes of diagnosis 
should precede the application of the forceps. It is absolutely essential 
that all doubt as to the position and presentation should be removed. Pre- 
vious examinations may have been unsatisfactory, but now, with otir 
patient unconscious and relaxed, previous difficulties disappear and doubt- 
ful conditions become plain. It is only by this final examination that we 
can be assured of the exact position of the head and of the diameter in 
which the forceps should be applied. In many cases it is only in this 
way that we can be sure that the forceps operation is really indicated 
at all. Much harm is constantly resulting from neglect of this final exam- 
ination. Now and then the obstetrical consultant is called to see a patient 
who has been subjected to prolonged eflforts with the forceps which might 
and should have been avoided had this precaution been taken. 

If the head is well down in the pelvic cavity the diagnosis can usually 
be made by means of the sutures and fontanelles, but if the head is high 
or the scalp so much swollen that the sutures cannot be plainly made out, 
it is well to introduce the half-hand and locate the posterior ear, thus 
removing all doubt. 



586 



OBSTETRIC SURGERY 



The Low Operation 

Everything being in readiness, the operator proceeds to introduce the 
first blade, which is usually the left. The blade is first held perpendicu- 
larly with the concavity of the blade toward the vulva, as shown in Fig. 
348. The handle should be held with the tips of the thumb and fingers, 
somewhat as one would hold a pen. A clumsy or inexperienced operator 



c<^ 




Fig. 348. — Introduction of left blade. 

is recognized by the fact that he grasps the handle in the full hand as 
one would wield an ice-pick (Figs. 349 and 350). In this way all delicacy 
of touch is lost and the operator is much more likely to inflict unnecessary 
traumatism upon the maternal structures. 

The method of introducing the blades is important. Two fingers of 
the right hand are passed into the vagina to serve as a guide. The posi- 
tion of the head has already been determined and the chief business of the 
guiding fingers is to make sure that the blade passes within the cervix 



THE FORCEPS 



587 



(Fis 



351^ 



Some writers advise the introduction of the entire hand. 



procedure which in my experience is rarely called for and is certainly 
highly undesirable, especially if the patient is a primipara and the operator 
The tip of the blade is now passed into the vagina by 

Fig. 349. 



has a large hand 



Fig. 350. 




Fig- 349.— Incorrect method of holding the forceps blade during introduction. 
^IG. 3oO.— Correct method of holdmg the forceps blade during the introduction. Only the tips of 

the fingers are used. 

way of the posterior commissure and just a little to the left of the hollow 
of the sacrum. As the tip passes within the cervix, beyond reach of the 
fingers, the handle is depressed and carried with a rotary motion toward the 
patient's right side, when, if all is well, it glides into place without trouble. 
V> hen the handle is horizontal at the vulva the introduction is complete. 



588 



OBSTETRIC SURGERY 



The common mistake of the begmner is to present the tip of the blade 
at the side of the vulva and tn' to push it directly into place at the side 
of the head. I have often seen this result in several fruitless attempts, 
to the confusion of the operator and the disadvantage of the patient. 

When the left blade is in position its handle is depressed, carried to the 
right and held in position by an assistant in order to make easier the intro- 
duction of its fellow. The operator, however, soon learns to dispense 
with the assistant in easy cases. 

We come now to the introduction of the second blade, which is usually 




Fig. 351. — The guiding hand protects the cervix. 



the right (Fig. 352). This is somewhat more difficult, owing to the 
presence in the vagina of the shank of the left blade, and hence there are 
usually more lacerations of the right side of the vulva and vagina after 
forceps operations than of the left. This difficulty is overcome and 
maternal traumatism minimized bv introducing the tip of the blade " fiat- 
wise " above the shank of its fellow, and passing it as nearly as possible 
into the hollow of the sacrum, whence it can be rotated to a position 
opposite the first. 

Locking. — In the low operation the occiput has rotated under the 
symphysis, or at least has descended so far that its rotation is completed 
during the locking of the blades or at the first traction. The sides of the 
head coincide with the sides of the pelvis and the second blade falls 
naturally into place. If, however, the head is very large or has been much 
moulded, there may be some difficulty in this respect, and such difficulty is 
quite often encountered in the median and high operations. 



THE FORCEPS 



589 



The trouble is most often due to the fact that the second blaae has 
not been adjusted to a position opposite its fellow. In this case the tour 
dc spire may be practised, or the blade gently urged into place by the 
fingers in the vagina. In other cases one blade may not have been intro- 
duced quite as far as the other. If neither of these causes obtains, locking 
may sometimes be eltected by carrying the handles backward against 
the perineum and at the same time rotating them outward. In other 







Fig. 352. — Introduction of right blade. An assistant holds handle of left blade out of the way. 

cases a change of instrument may solve the question, e.g., an instrument 
with a moderate pelvic curve is not as easily locked when the head is at 
or near the pelvic brim, and a well-marked pelvic curve makes locking 
at the outlet a more difficult matter. 

As soon as the instrument is locked, and while the first traction is being 
made, the fetal heart should be auscultated. This practical suggestion, 
emphasized by DeLee, is of great value, for it occasionally happens that 
a prolapsed cord, or a cord encircling the neck, is compressed bv the tips 



590 OBSTETRIC SURGERY 

of the forceps. If this pressure is long continued the child is promptly 
asphyxiated. If the heart-sounds, which were normal before the appU- 
cation of the forceps, become faint or disappear when the forceps are 
closed, and before much traction is made, the instrument should be removed 
and carefully reapplied under the guidance of the fingers or half-hand, 
which should endeavor to locate the cord and push it out of the way. 

Tractions. — The first traction is tentative and made with one hand, 
while a finger of the other hand applied to the occiput notes that the head 
is advancing and that the forceps are not slipping. Tractions should be 
made at interv^als of two or three minutes in imitation of natural labor, 
and should not as a rule exceed one minute in duration, thus avoiding 
prolonged compression of the fetal head. Between tractions the grip upon 
the forceps should he loosened and the handles separated and allowed 
to remain separate until the next traction ; another method of limiting 
compression of the fetal head. 

One or two horizontal tractions suffice to give the operator his bearings 
and to bring the occiput well under the pubic arch. What remains is to 
accomplish, with the forceps, the extension of the head. This is done by 
the so-called pump handle traction. The operator standing at one side 
of his patient manipulates the forceps with one hand, while the other 
hand at the vulva guides and controls the action of the forceps and esti- 
mates the distention of the perineum. Extension of the head is produced 
by depressing the handles toward the mother's abdomen. Here they 
occupy an almost horizontal position, and if the forceps have a marked 
pelvic curve may even come into contact with the abdomen, thus inter- 
fering somewhat with delivery. The head is then flexed by reversing the 
movement and bringing the handles to a position approaching the per- 
pendicular. In this way the head is alternately flexed and extended in 
imitation of the natural mechanism, a larger and larger segment appearing 
with each flexion of the head, until the operator judges that there is sufli- 
cient distention of the perineum to permit the easy passage of the head. 
The usual mistake of the careless or incompetent operator at this time 
is to bring the head horizontally and rapidly through the vulva. In this 
way extensive lacerations are often produced and even in simple and 
easy cases irremediable harm may be done. 

The operator should remember that very little compression of the 
handles is necessary at this time and he should on no account neglect the 
examination of the fetal heart. This is especially true in the case of 
elderly primiparae with small and rigid soft parts. 

Shall the forceps be removed during the delivery of the head? There 
has been much discussion over this point. ]\Iy own conclusions are as 
follows: If the patient is a primipara, and the adaptation is close, it is 
better to remove the forceps and to complete the delivery by the method 
described in connection with the management of labor. This is especially 
true when the Tarnier instrument is used, since the blades of this instru- 



THE FORCEPS 591 

ment are somewhat larger and heavier than those of other models. In the 
case of a multipara, however, or in any case in which there is plenty of 
room it is more convenient, and probably better practice, to allow the 
forceps to remain in position until with the delivery of the head the 
instrument falls of its own weight into the hand of the operator. 

Pendulum Tractions. — Some teachers advise a side to side move- 
ment of the forceps in traction, the so-called pendulum movement. Others 
vigorously condemn the practice as unnatural and dangerous. My own 
belief is that such tractions are never justifiable when the head is high 
in the pelvis, and seldom justifiable at any stage of labor. Experience, 
however, has taught me that when the head is blocked at the pelvic outlet 
and direct tractions are without result, moderate and limited lateral move- 
ments may overcome the difficulty. Instances of this kind are found in 
cases of unusual size of the fetal head and of moderate contraction at the 
pelvic outlet. Here, as elsewhere, clinical experience must outweigh 
preconceived ideas and theoretical considerations however plausible. 

The Median Operation 

This is more difficult than the low operation, and if the head is large, 
or the position unfavorable, may tax the resources of a good operator. 
The head is in the pelvic cavity behind the symphysis, and must be brought 
to the floor of the pelvis before horizontal tractions can be made. An- 
other difficulty is that the head has not completed its movement of rotation. 
It occupies one of the oblique diameters of the pelvis or perhaps it is still 
transverse. 

The application is somewhat more difficult. If the forceps are to be 
applied to the sides of the head they must also occupy one of the oblique 
diameters. Let us suppose that the position is L. O. A., the most common 
one. Here the left blade is introduced in the usual manner but instead of 
being brought to the side of the pelvis, as in the low operation, it is left 
in the sacro-iliac articulation at the side of the head, i.e., over the posterior 
ear of the foetus. In difficult cases the ear may be located by the half- 
hand in the vagina. The right blade is next introduced as already 
described, but instead of being left at the side of the pelvis, as in the low 
operation, it is carried farther forward until it occupies a position opposite 
its fellow. This is the tour de spire of Madame LaChapelle. It is accom- 
plished by lowering the handle, carrying it toward the left buttock of 
the mother, and at the same time rotating it slightly upon its axis. This 
movement is not always easy of accomplishment, and may occasionally 
require the aid of the guiding fingers in the vagina, gently urging the blade 
along. When the instrument is locked its concavity looks forward and 
to the left, i.e., toward the occiput. 

But the head is still behind the symphysis. Horizontal tractions are 
out of the question. We cannot make traction in a curve. How then 
are w^e to get the head around the symphysis? If the old forceps model is 



592 OBSTETRIC SURGERY 

used there are two means at our disposal. One is to carry the forceps 
handles as far back as the perineum will permit and make gradual and 
intermittent traction. The other is to practise the manoeuvre of Pajot. 
In this manoeuvre the operator seizes the forceps with one hand in the 
neighborhood of the lock and makes pressure directly downward, while 
with the other he grasps the handles and makes horizontal traction. 
Neither of these methods is ideal, though either may work well in an easy 
case. In the first a long time is required to bring the head to the floor 
of the pelvis and a large part of the force used is worse than wasted since 
it involves injurious pressure upon the maternal tissues behind the sym- 
physis. The latter is a clumsy and imperfect imitation of the axis-traction 
principle, and involves severe compression of the fetal head. If one does 
not use the axis-traction model, some modification of Pajot's method is to 
be preferred ; but the operator should be content with a gradual advance 
and should strive to limit the compression of the fetal head to a minimum. 

How should the forceps be held? It has always seemed to me an 
absurdity to formulate precise rules as to how the forceps should be 
grasped, and to expect all men to hold the instrument in exactly the same 
manner. I think this is shown by the fact that good operators of large 
experience have different methods of holding the instrument. Indeed, 
most men find it convenient to change the grasp of the handles occasion- 
ally during the course of the operation. This of itself proves that there 
is no one method to be followed by every one and at all times. 

In operating without the axis-traction model it is impossible always 
to be sure that one is pulling in the right direction, and if progress is 
not satisfactory one should change the direction of the tractions and 
watch the result. A common error of the inexperienced operator is to 
raise the handles too early, i.e., before the occiput is well under the pubic 
arch. Tractions are made at intervals in imitation of normal labor. The 
operator should keep his elbows close to his sides and use only his fore- 
arms in pulling. To use the weight of the body is a relic of barbarism. 
It is better that the operator should sit at his work rather than stand. 
The temptation to use force is not so great, and the operator being more 
at ease can better concentrate his attention upon his work. 

In all difficult cases pressure applied to the fundus is of greatest 
assistance. 

Personally, I believe that the Tarnier instrument should be used in 
median operations. I believe that it is a great mistake to limit its employ-- 
ment to the high operation, as is so often advised; or at least taken for 
granted. Experience has taught me that by its use the head can usually 
be brought to the floor of the pelvis with much less exertion and trouble 
on the part of the operator, and, what is more important, with much less 
maternal traumatism and less compression of the fetal head. 

Forceps in the R. O. A. Position. — Here the sagittal suture is in the 
left oblique diameter and the forceps, if they are to He at the sides of the 



THE FORCEPS 593 

head, must be applied in the right obhque diameter. The application is 
the same, luiitatis mutandis, as in the L. O. A. position with this important 
exception. The right or posterior blade must be introduced first, because 
the presence of the left blade rotated anteriorly would make the intro- 
duction of the right blade difficult or impossible. After the blades have 
been introduced it will be found that locking is impossible, as the handle 
of the left blade is in front of that of the right. This difficulty, however, 
is readily overcome by rotating the handles around each other, the dccroise- 
ment of the French writers (Fig. 353) . The handles are seized each in the 



i 



\ 





Copyright, 1912, D. Appleton & Co. 
Fig. 353. — Locking of forceps made possible by rotating handles around each other. (After Williams.) 

full hand and gently drawn in opposite directions until the right one can 
be carried around and above the left. There will, as a rule, be no further 
trouble in locking. 

Alany students and practitioners, who have been incorrectly taught 
at the outset, seem to regard this passing of the anterior blade first and 
the subsequent rotation of the handles as an impracticable refinement. It 
is, however, easier than the ordinary method. 

The entire manoeuvre is rather difficult to explain on paper, and the 
reader is advised to test the matter on the manikin, or to observe appli- 
cation carefully in his next case. It is an indispensable part of the forceps 
38 



594 OBSTETRIC SURGERY 

operation as practised by modern obstetricians and is especially useful in 
L. O. P. cases. 

Forceps in Transverse Position. — In the transverse position the sag- 
ittal suture occupies the transverse diameter of the pelvis, and if the 
forceps are applied to the sides of the head they must be applied in the 
anteroposterior diameter of the pelvis, i.e., with one blade behind the 
symphysis and the other in the hollow of the sacrum. This application 
is advised by some writers, while others say it is impossible. I know that 
it is possible, because I have myself performed it, but I do not advise 
its general use. If the pelvis is contracted, or the head of unusual size, 
there is considerable danger of injury to the maternal soft parts. As a 
rule, it is better to convert the position into an oblique one manually before 
applying the forceps. If this cannot be accomplished the forceps should 
be applied in an oblique diameter of the pelvis. If the occiput is directed 
to the left, the forceps are applied as in the L. O. A. position, i.e., in the 
right oblique diameter. If it is directed to the right the application should 
be as in the R. O. A. position. One blade will then lie over the mastoid 
region, while the other is placed over the temporal region of the other side. 
This application has, of itself, a tendency to promote anterior rotation of 
the occiput. 

Cases in Which the Forceps Cannot be Applied to the Sides of the 
Fetal Head. — It is easy for the writers of text-books to lay down exact 
rules for the application of forceps and to assume that these rules are 
applicable to every case. In actual practice, however, we sometimes meet 
cases in which it is not possible to make an exact cephalic application. In 
my experience these are usually cases in which the head is unusually large, 
or in which there has been much moulding and a long caput is present. 
In such instances, even if the first blade is correctly applied, it may be 
difficult or impossible to rotate its fellow to a position exactly opposite. 
If unable to make an exact cephalic application we should make the appli- 
cation as oblique as possible. Several trials may be necessary before we 
can make any application at all, and moderate force may be necessary in 
locking. In such cases the Tarnier forceps will often succeed when other 
instruments fail. 

The High Operation 

If the head is above the brim and cannot be made to engage by supra- 
pubic pressure, the forceps operation is usually contra-indicated. In some 
instances, however, pressure over the fundus transforms such a case into 
one which may be delivered by a median or even a low operation. I have 
many times known this to succeed. The cervix should be dilated, the 
membranes ruptured and the bladder empty. I recall a recent case in 
which the head was above the brim of the pelvis. The patient was a 
primipara. I had failed to secure a good application with either the 
Elliott or the Tarnier forceps and feared that I would be obliged to 



THE FORCEPS 595 

resort to version, with possible loss of the child. Before attempting this, 
however, I instructed my assistant to make strong pressure over the 
fundus. To my great satisfaction the head descended to the floor of the 
pelvis and the subsequent extraction was easy. 

In most high cases a segment of the head has entered the brim but the 
greatest diameter still remains above. Here we must be content with an 
oblique application, since an exact application to the sides of the head 
makes delivery a mechanical impossibility. 

The blades should be introduced as in the median operation, though of 
course they enter the birth canal more deeply. Tractions should be careful 
and tentative and never pushed to the extent of brute force. Expedients 
that may be tried are putting the patient in the Walcher position and 
turning her upon the side. If the old model of forceps is used, Pajot's 
manoeuvre may be tried, the hand at the lock making pressure directly 
downward, or tractions may be made as far backward as the perineum will 
permit. Pressure from above may prove very useful. To undertake 
a high or a difficult median forceps operation without the axis-traction 
instrument is like treating a case of diphtheria without antitoxin. If a 
few tractions do not result in the advancement of the head, the forceps 
should be removed and some other method of delivery adopted. As I 
have often demonstrated, a careful attempt of this kind does not neces- 
sarily injure the foetus. 

The high forceps operation is to be regarded not as an operation that 
once begun must be finished at any cost, but as an alternative to version 
or some other method of delivery. It is to be regarded as a means of 
diagnosis, a test of the operability of the case in hand. 

It is of the greatest importance that the obstetrician should be able to 
recognize those cases that cannot be delivered by the forceps. Fruitless 
attempts at delivery in these cases may not only seriously injure the 
mother, but are almost certain to prevent the subsequent delivery of a 
living child. If with a good application three or four tractions have no 
effect whatever, it is unlikely that further effort will do good, and if it does 
no good it is certain to do harm. The experienced obstetrician who has 
seen a few of these cases soon learns to recognize a certain stony immo- 
bility, an absolute lack of response to traction, that characterizes the 
inoperable case. Cases in which a satisfactory application cannot be 
made after two or three trials, in which the instrument persists in slipping, 
or in which locking is impossible without the use of great force, belono- 
in the same category. 

The Axis-traction Forceps 

It is self-evident that ideal traction, i.e., traction that is always in the 
axis of the pelvic canal, cannot be made with the ordinary forceps. ]\Iuch 
of the force is wasted in pressure against the symphysis ; indeed, it is worse 
than wasted, since it involves traumatism of the maternal tissues. This 



596 



OBSTETRIC SURGERY 



fact has long been recognized, and in the early part of the last century 
attempts were made to correct the deficiency by giving the handles an 
extended backward curve. Hermann, in 1844, devised an axis-traction 
instrument which was correct in principle, but which was not adapted 
to practical use. Chassaigny, of Lyons, clearly appreciated the principles 
of traction an centre de figure and devoted a large part of his life to its 
study, but used tapes instead of traction handles. It was reserved for 
Tarnier to devise in 1877 the first really effective and practical instrument. 
The construction of the axis-traction forceps is best appreciated by a 
glance at Fig. 354, which represents the latest modification of the Tarnier 
instrument. Traction is made not upon the true handles (A), as in the 




Fig. 354- — Latest modification of Tarnier forceps- 

ordinary operation, but upon the traction handles (B), which are con- 
nected with the traction rods (C) by a series of movable joints. Thus, the 
handles proper swing free in the pelvis and indicate the direction in which 
traction should be made, while the head, its movements in no way restricted 
or controlled by the operator, moves automatically in the direction of least 
resistance, going through the movements of rotation and descent as in 
normal labor. I am strongly of the opinion that this is fully as important 
as traction in the axis of the pelvic brim. 

With the ordinary instrument the operator is as likely to oppose as 
he is to favor the normal mechanism of labor, and is obliged to pull very 
much harder. In pulling harder he must compress the fetal head propor- 
tionately, and the danger to the child is enormously increased. 

With the Tarnier instrument there is usually very little compressive 



THE FORCEPS 597 

force exerted: first, because the instrument is so constructed that the 
blades do not readily separate, and second, because so little traction force 
is necessar}-, one hand often being sufficient to do all the work. For 
these reasons it seems to me that the axis-traction forceps should be 
employed in all difficult median operations as well as in the high opera- 
tion, and I firmly believe that this would save the lives of many children. 

The movable joints connecting the traction rods with the traction 
handle enable the operator to hold the traction rods horizontally when the 
head is seized obliquely or even when the application is transverse. This 
feature is, I believe, peculiar to the Tarnier model. 

Technic. — The axis-traction instrument may seem a little complicated 
at first, but after using it once or twice all difficulties vanish. Correct 
descriptions and illustrations, however, are rare. In the following descrip- 
tion it is assumed that the Tarnier instrument is used. It is sold in New 
York in three sizes. I am accustomed to advise my students to secure the 
largest. The dift'erence is chiefly in the length. I also advise them to 
avoid substitutes that are recommended as lighter and presumably safer. 
I have tried elsewhere to show the fallacy of the idea that a forceps that 
is short and weak is therefore a safe instrument. In reality it is not a whit 
safer, but is really more dangerous, because far less efficient, and in some 
cases quite useless. This is particularly true of the axis-traction model. 
When the axis-traction forceps is used, it is because the case is a difficult 
one, and to select an instrument that is short and weak is to defeat the 
very object for which it is employed. 

The instrument is applied in the usual manner, the blades being adjusted 
to the sides of the head, as in the ordinary operation. The traction rods 
are then loosened and attached to the traction handle. The fixation screw, 
sometimes improperly called the compression screw, is then screwed up, 
just enough to keep the blades front separating and no more. Most direc- 
tions are incorrect upon this point. It is a fatal error to use the screw 
as a compressor. In this way one of the chief advantages of axis-traction, 
the absence of head compression, is nullified. No compression is necessary. 
In fact, if one forgets to use the screw at all, the forceps, if correctly 
applied, will not slip under any ordinary traction. The length and solidity 
of the blades in the Tarnier model, and the fact that the French lock holds 
them solidly in position, are the factors that prevent slipping. 

Tractions are made at intervals, as with the ordinary instrument. 
Between tractions the fixation screw is loosened, and the handles separated, 
in order to avoid the possibility of compression. 

The traction rods and the whole traction apparatus are kept as close 
to the handles proper as is possible without touching them. The handles 
then swing free, and afford an index, not only of the progress of the head, 
but also of direction in which traction should be made upon traction handles. 
As the head descends to floor of pelvis and handles rise, the traction rods 
are made to follow them, never touching them, however (Fig. 355). 



598 



OBSTETRIC SURGERY 



A. common mistake of the beginner is to use the traction apparatus to 
push up the handles. Another, and a more serious mistake, is to depress 
the traction handles with the idea that he is pulling in the axis of the 
superior strait. This is a gross error and may result in the slipping of the 
forceps, with serious consequences (Figs. 356 and 357). 

The operator should satisfy himself occasionally that the rising of the 




Fig. 355. — Traction with the Tarnier forceps. Note that the handles are rising, showing that the 

head is moving down. 

handles is not due to slipping. For this purpose one finger palpates the 
head, while traction is made with the other hand. 

When the head is well down on the pelvic floor, most operators remove 
the axis-traction attachment and complete the extraction without it. This 
is not always necessary since, as has been shown by the Edinboro school, 
the axis-traction principle works as well at the outlet as anywhere else. 
There are cases, however, in which the Tarnier instrument, owing to its 
marked pelvic curve, does not serve as well at the outlet, and progress is 



THE FORCEPS 



599 




Fig. 356. — Incorrect method of making traction. The operator has depressed the traction handles 
with the idea that he is making traction in the axis of the superior strait. A dangerous blunder. 




Fig. 



357. — Correct method of making traction with the Tarnier forceps, 
mately parallel with the shanks. 



The traction rods are approxi- 



600 



OBSTETRIC SURGERY 



delayed. By replacing the instrument with an ordinary forceps having 
a very moderate pelvic curve delivery is easily effected. Such an instru- 
ment is, as already noted, much more convenient in bringing the head 
through the vulva. 

Forceps in Posterior Positions of the Occiput. — If the head is at the 
brim and the occiput posterior, version is ordinarily indicated. The high 
forceps operation is sufficiently difficult under normal conditions. Even 




Fig. 358. — Same case. Traction apparatus has been removed and the head is being delivered as in the 

ordinary operation. 

if the head has become engaged, and its greatest diameter is a little below 
the brim, delivery with the ordinary forceps is a difficult and dangerous 
task and, if the operator has only such an instrument, version, if prac- 
ticable, is still the operation of choice. If he has a good axis-traction 
instrument he can probably succeed, provided the head is not of unusual 
size. At all events a cautious attempt is justifiable. 

In the majority of cases the delay occurs at the pelvic floor. If the 
cause of delay is unrecognized and the operator attempts to deliver the 
case in the usual manner, he may find delivery difficult or impossible. If he 



THE FORCEPS 601 

succeeds it may be only after prolonged and severe traction. If the head is 
large the foetus may be lost and the mother subjected to severe injury. I 
have seen lacerations of the third degree. 

Forceps should not be hastily applied in these cases, since rotation often 
occurs at the last moment and contrary to all expectation. In some cases, 
however, suffering is severe or exhaustion is threatened, or perhaps the 
foetus gives evidence of impending asphyxia. What is to be done? 

Let us take the R. O. P., the most common of the posterior positions. 
The fetal head occupies the right oblique diameter, the same diameter as 
in the usual L. O. A. position. The forceps, then, are applied in the left 
oblique diameter, as in the L. O. A. position, but the tips now look toward 
the position of the head, introducing the half-hand and locating the 
posterior ear, if necessary, before applying the left blade. The right 
blade is then introduced and rotated to a position opposite its fellow. 

The forceps having been locked, the next step is to raise the handles, 
thus flexing the head, since, as we have already learned, there is always 
more or less extension of the head in these cases. This movement causes 
the handles to point toward the left thigh of the mother. A straight 
forceps would perhaps be the ideal instrument here, since the operator 
would then have but one curve to bear in mind. When, however, the 
handles of the forceps have been carried toward one thigh of the mother, 
the cur\-ed instrument becomes " to all intents and purposes a straight 
forceps for the time being " f Brodhead) 

^Moderate traction is now made, and at the same time a rotary motion 
is imparted to the handles, which are carried to the mother's left. This 
manoeuvre brings the occiput to the right. One or two such tractions 
usually suffice to bring the occiput to a transverse position. After each 
traction the head is held in its new position for a minute or more without, 
however, making much compression until a contraction occurs or another 
traction is made. In this way time is given for the rotation of the body 
to follow that of the head, and the latter does not slip back to its former 
position. When the occiput has become anterior the forceps have become 
inverted and must be removed. Firm pressure upon the fundus now serves 
to keep the head in its new position and perhaps even to effect delivery. 
If not, the forceps are re-applied and extraction completed, according to 
the rules already laid down for the management of R. O. A. cases. 

If the occiput is posterior and to the left, the procedure is relatively 
the same as that just described. Since the forceps are applied in the 
right oblique diameter it is easier and better to apply the right blade first, 
as in the R. O. A. position. 

In practice all this is not as formidable as it seems. It is necessary, 
of course, that the operator know how to make a diagnosis of position, 
and that he understand the technic of the forceps operation, but that may 
be said, and with even more truth, of the high forceps operation. I recall 
that my first attempt proved much easier than I had expected. I do not 



602 



OBSTETRIC SURGERY 



5hare the fear of this operation expressed by some writers. Indeed, I 
beheve that it gives better results for both mother and child than forceps 
extraction with the occiput remaining posterior, which is usually the only 
alternative. If the operation cannot be easily performed it should not be 
performed at all. Forcible rotation is never justifiable (Fig. 359). 

If a careful attempt at rotation fails, or if the occiput has rotated into 
the hollow of the sacrum, the head must be delivered with the occiput 
posterior. Horizontal tractions should be kept up until the forehead 
appears beneath the symphysis. This is the most important thing to be 
remembered in these cases. The operator should work carefully and 
patiently, meanwhile carefully watching the fetal 
heart. The mistake of the inexperienced opera- 
tor, or of the man who has failed to make a 
diagnosis and thinks he is dealing with an an- 
terior position, is to raise the handles too soon. 
This, of course, delays progress and causes 
undue traumatism of the tissues behind the 
symphysis and unnecessar}" compression of the 
fetal head. It is not until the forehead has 
escaped from beneath the symphysis that the 
handles of the forceps are slowly raised, thus 
flexing the head and lifting the occiput over 
the perineum. They are then depressed, causing 
the nose, mouth and chin to pass successively 
beneath the pubic arch, thus completing the 
delivery of the head. 

Anterior rotation of the occiput by means 
of the axis-traction forceps is a favorite method 
in France. The forceps are applied as in the 
<)f^h?ad^intrfh?foTiow°o?*the mcthod already described, and the handles are 
Jo's^Hor dfa'mftTrnrd%"sceS raiscd in ordcr to produce flexion of the head. 
without rotation. 'p]^g Operator then makes traction upon the rods 

with one hand while with the other hand he rotates the handles proper. 
I have frequently rotated the head in this manner, after having brought 
it to the floor of the pelvis by means of the Tarnier instrument. In the 
majority of cases, however, the head is already at the pelvic floor when 
the necessity for interference arises, and in these cases the operation 
already described is simpler and more easily performed (Figs. 360 
and 361). 

Forceps in Breech Presentation. — The application of the forceps 
to the breech may occasionally be called for. The indications are given 
in the chapter on breech presentations. The Tarnier instrument is to be 
preferred, and an exact bitrochanteric application secured. This is easily 
accomplished, since the breech does not fill the pelvic brim, and the blades 
are easily urged or guided into position. The hold over the trochanters 




THE FORCEPS 



603 



is secure and least likely to injure the foetus. Tractions should be inter- 
mittent and gentle. If too much force is used the forceps will slip and there 
is also increased danger of injuring the foetus. Strong pressure upon the 
fundus should be kept up during the tractions. Sometimes moderate 
continuous traction is of advantage. Of course, there is not the same 
danger from compression as in cephalic presentations. 

As soon as the breech has been brought down into the pelvic cavity 
the forceps should be removed and the remainder of the delivery conducted 
as in any breech presentation. 

Forceps in Face Presentation. — In a face presentation at the pelvic 
brim version is the operation of choice. In face presentation with chin 




Fig. 360. — Application of forceps in R. O. P. position. Head poorly flexed. 

anterior and the head low in the pelvis the use of the forceps may become 
necessary. An exact application to the sides of the head is of the greatest 
importance ; first, to prevent pressure upon the child's neck, and second, 
to prevent slipping. The forceps penetrate more deeply than in occiput 
presentations owing to the long occipitomental diameter which they must 
cover. The rotation of the chin under the symphysis is cautiously encour- 
aged by imparting a rotary motion to the forceps during traction. When 
the chin has rotated under the subpubic arch, the handles are gradually 
raised and the head is born by a movement of flexion. During the period 
of expulsion the trachea is pressed against the subpubic arch. The oper- 
ator should guard against this by not raising the handles anv more than is 



604 



OBSTETRIC SURGERY 



absolutely necessary and by hastening delivery as much as is consistent 
with prudence. 

If the position is transverse and immediate delivery indicated, an effort 



f •■ 



^ 




-,. 



Fig. 361. — Application of forceps in R. O. P. position. Flexion produced by raising the handles. 

should be made to rotate the chin to the front by the hand before applying- 
forceps. The instrument is highly dangerous to the foetus in the transverse 
position, since one is likely to compress the trachea. Even if one tries to 



THE FORCEPS 605 

apply the forceps to the sides of the head one is apt to make an oblique 
application in the end. Fabre advises that if forceps are used those with 
short blades should be employed as less likely to press upon the child's neck. 

If the chin is posterior, and the head of normal size, forceps are contra- 
indicated, since extraction is impossible. It is better as a rule to try to 
pass the second blade directly into position, since the irregularities and 
projections of the face make the tour de spire a difficult matter (Fig. 362). 

Forceps to the After-coming Head. — Shall the forceps be applied to 
the after-coming head? This question has been much discussed, and 
there is still lack of agreement. Personally, I have usually succeeded by 
the use of the Mauriceau method and have come to regard this as the most 



of-; 



/ 

I 







X 



Fig. 362. — Application of the forceps in face presentation. 

rapid and effectual of all methods. The factor of rapidity is most 
important here on account of the great danger to the child and an experi- 
enced operator can usually effect delivery in less time than it takes to apply 
the forceps. Nevertheless, in view of the testimony of many good opera- 
tors that they have occasionally succeeded with the forceps, after the 
failure of other methods, it is wise to have the instrument sterilized and 
ready for use. 

I do'Tlot believe that the use of the forceps above the brim is indicated, 
and I do believe that it is as hazardous to the mother as any other hasty 



606 OBSTETRIC SURGERY 

high forceps operation. There is, however, a class of cases in which the 
head is delayed after passing the brim of the pelvis, and this in spite of 
shoulder and jaw traction and suprapubic pressure. In some of these 
cases the delay is due to insufhcient dilatation of the cervix, in others to 
unusual size of the head or to an occipitofrontal diameter much prolonged 
by moulding. In others, perhaps, by a moderate contraction of the pelvic 
outlet, which has been allowed to pass unnoticed. I have never seen these 
cases described but have met them occasionally. It is in these cases, I 
believe, that the application of the forceps sometimes hastens matters. 

The method of application is well shown in Fig. 363. The feet of the 
child are carried upward and backward over the mother's abdomen and 
the forceps passed along the abdominal surface of the child. They should 
be applied to the sides of the head if possible. One or two horizontal trac- 
tions should bring the chin under the symphysis. The handles are then 
raised, flexing the head and bringing face, forehead and occiput over the 
perineum. A forceps with a moderate pelvic curve is to be preferred, sa 
that the handles will not strike against the child's body as they are carried 
upward. The operator should be careful not to compress the cord with 
a forceps blade. 

After every median or high operation, and whenever the cervix has 
been manually dilated, the latter should be inspected, and, if necessary, 
repaired. Lacerations of the perineum and pelvic floor should also receive 
attention. Douches at this time are quite unnecessary and, I believe, do 
more harm than good. Nothing has been introduced into the uterus except 
the forceps blades, which are, or should be, sterile, and the flow of liquor 
amnii and blood, the latter being quite free in forceps operations, constitutes 
a sufficient irrigation. The usual time should be allowed for the expulsion 
of the placenta. ]\Iany seem to think that it is necessary to hurry the 
expulsion of the placenta after a forceps operation. This is a mistake 
and, as in normal labor, results in unnecessary blood loss. The latter is 
especially undesirable after a forceps operation, in which the patient always 
loses more blood than in normal labor, and in w^hich the anaesthetic creates 
a tendency to hemorrhage. If there is no tendency to bleeding the usual 
time should be allowed for the expulsion of the placenta, the uterus being 
carefully watched meanwhile. After the delivery of the placenta it is a 
wise precaution to administer ergot and the fundus should be carefully 
watched for two hours. 

Summary. — As the result of considerable experience in this field, I 
venture the following advice to those of my readers who are interested in 
this subject: 

Every practitioner should have two pairs of forceps, one of which 
should be an axis-traction model, the other an instrument like the Simpson 
forceps, with a very moderate pelvic curve. 

All short and weak Instruments should be avoided. 

All forceps operations should be performed upon a table. 



THE FORCEPS 



607 




608 OBSTETRIC SURGERY 

The use of the catheter as a final preHminary measure should never 
be forgotten. 

Before any attempt to apply the blades, a final examination for diagnosis 
should be made. 

Prolonged and profound anaesthesia should be avoided. 

Do not give too much of the anaesthetic or give it too long. 

The forceps handles should always be separated between tractions. 

The frequent auscultation of the fetal heart should never be forgotten. 

The forceps operation is the most important operation in surgery. 
Two lives are at stake. Such an operation should be carefully and fre- 
quently rehearsed. Whenever possible, it should be performed under the 
most favorable circumstances. He who intends to practise obstetrics 
should learn the principles of the operation and apply them from the 
start, and he who has become accustomed to careless and slovenly methods 
should discard his old habits and resolutely begin anew. 



CHAPTER XXVIII 
VERSION 

Definition. — By version is meant the substitution of one pole or part 
of the foetus for another at the pelvic brim. The object, of course, is to 
substitute a favorable for an unfavorable presentation. 

Varieties. — There are three kinds of version. In cephalic version, the 
head is made to present ; in podalic version, the foot ; and in pelvic version, 
the breech. 

Methods. — There are also three methods of performing version — ■ 
the external, the internal, and the combined. Internal version requires the 
introduction of the hand into the uterine cavity. In the combined, bipolar, 
or Braxton Hicks method, one or two fingers only are passed into the 
uterus, the external hand assisting at the fundus. In external version all 
manipulations are made through the abdominal wall. 

Internal podalic version, since it is the most important and most 
frequently performed, will be first considered. 

Internal Podalic Version 

Indications. — In a general way it may be said that internal podalic 
A-ersion is indicated in all cases in which speedy delivery is necessary, and 
in which such delivery cannot without undue risk be accomplished by the 
forceps. ^Manifestly, the operation has a wide field of usefulness. In 
some cases, as in eclampsia, placenta prsevia, and accidental hemorrhage, 
it is undertaken primarily in the interest of the mother; in others, as in 
prolapse of the cord, in the interest of the child. In the majority of 
cases, however, it is employed as the quickest and safest method of ending 
a situation that has become intolerable and threatens the safety of mother 
and child alike. 

When the head is arrested at the brim in an unfavorable position, 
A-ersion is usually indicated. Examples of this are to be found in face and 
brow presentations, and in posterior positions of the occiput. Such cases 
are not suitable for the forceps, and theoretical and traditional methods 
of replacement are of little use ; the latter, indeed, do far more harm than 
good in the majority of cases. When the head is at or above the brim and 
cannot be made to engage, version is usually much safer than the forceps 
operation, even though the position be normal. 

In all cases of delayed first stage, in which there is apparently no serious 

mechanical disproportion, but in which the forceps fail and the child is 

living and viable, version is the operation of choice. Experience should 

soon teach the observant accoucheur when to lay aside the forceps in 

39 609 



610 OBSTETRIC SURGERY 

these cases. Untold harm is often done by prolonged and forcible traction 
in cases that are unfavorable for the forceps but may be easily delivered 
by version. 

In transverse presentation, we have, of course, an absolute and typical 
indication for the performance of version, and this is also true of many 
cases of prolapse of the cord. In general, however, the accoucheur will 
do better to bear in mind the general principles outlined above and to study 
carefully the subject of the choice between the forceps operation, con- 
sidered in the last chapter, and version. It is only in this way, and not 
by attempting the impossible task of memorizing a long list of special 
indications and particular cases, that he will succeed in reaching a correct 
decision. 

Contra-indications. — Aversion is usually contra-indicated w^hen forceps 
delivery is practicable and not attended by great risk to the mother, because 
the forceps operation ordinarily involves far less danger to the foetus. 
Even in easy versions the entrance of air into the uterine cavity, or the 
sometimes unavoidable handling of the cord, may cause premature inspira- 
tions, with resulting asphyxia, and when the foetus is of large size there 
is often unexpected delay in the bringing down of the extended arms and 
the delivery of the after-coming head. It must be admitted, however, that 
the skill of the individual operator plays a large part. A good forceps 
operator, and especially one who is familiar with the axis-traction instru- 
ment, can often deliver easily with the forceps when another would be 
obliged to resort to version with possible loss of the child. It is also contra- 
indicated in cases of transversely or generally contracted pelvis, because 
in such cases the long occipitofrontal diameter of the fetal head is brought 
into relation with the shortened transverse diameter of the pelvis. A head 
of average size is not likely to be successfully delivered by version through 
a flat pelvis if the conjugate diameter is less than 8 to lo centimetres. 

Version is contra-indicated in the case of a hydrocephalic foetus, and 
it should not be undertaken in the case of a dead foetus unless the operation 
promises to be an easy one. It is never justifiable to subject the mother to 
a difficult version in order to secure the merely aesthetic advantage of 
delivering an unmutilated child. 

It is, of course, contra-indicated when, after rupture of the membranes, 
the uterus is so tightly contracted about the foetus that under full anaes- 
thesia a knee or a foot can only be reached by the exercise of brute force. 

The statement so often made, however, that version is highly difficult 
and dangerous when performed some hours after the membranes have 
ruptured is incorrect. It is often possible, and even easy, to perform 
version, hours, or even days, after rupture of the membranes, especially 
when the uterine contractions have been weak, or active labor has not 
supen^ened. If version is apparently indicated in such a case, its practica- 
bility should be determined, not by theoretical considerations, but by actual 
-trial, by a cautious attempt under anaesthesia. 



VERSION 611 

Another statement often made by those who write from an academic, 
rather than a practical, stand-point is that version cannot be performed 
when the head is low in the pelvis. This simply shows lack of experience. 
It is, of course, true that under such circumstances it is often impossible 
and usually contra-indicated. Nevertheless, there are occasional cases of 
this kind in which the forceps fail and the delivery of a living child seems 
doubtful. In such an emergency the only way of finding out whether a 
version is practicable is to try. A cautious attempt to lift the head out 
of the pelvis, always with the cooperation and guidance of the external 
hand at the fundus, does no harm and may succeed. Now and then the 
operator finds to his surprise and relief that the whole operation is 
performed without difficulty. 

Finally, the student is often told that version should not be performed 
unless the cervix is fully dilated. This leaves him in a dilemma that is 
not only cruel but quite unnecessary. In many cases in which version is 
indicated, the head, because of some malposition, cannot descend. To 
wait for complete cerA'ical dilatation would be to wait until both mother 
and child succumbed. \\'hen version is indicated, dilatation of the cervix 
is indicated and should be performed. But more of this when we come 
to speak of the cervix as an obstacle to delivery. 

Technic. — The operation should be performed upon a table and with 
the usual aseptic precautions. A high table is preferable on account of 
the downward traction necessary. Special care should be taken to see 
that the abdomen is disinfected and covered with sterile towels, since the 
hand of the operator must be placed upon the fundus. The rectum should 
be empty and the patient should be catheterized. The effect of trying to 
express the after-coming head in the presence of a distended bladder can 
better be imagined than described. The catheter, so frequently left at 
home, is often the one instrument absolutely necessary. An enema should 
be given. A sterilized tape or fillet for securing a prolapsed hand may 
be needed, and a tenaculum, needles, needleholder, and sutures for repair 
of the cervix and perineum should not be forgotten. Full anaesthesia is 
necessary in version, especially in difficult version, since uterine relaxation 
must be secured, but the administration of the anaesthetic should be delayed 
until all other preparations have been made. In this way the dangers of 
shock, postpartum hemorrhage, and fetal narcosis are minimized. A 
competent assistant should be secured, if possible, to give the anaesthetic, 
and to watch the fetal heart. 

Position of the Patient. — Many operators prefer to have the patient 
in the lateral position, and this position has certain undeniable advantages. 
In my opinion, it is better to begin with the patient in the lithotomy 
position, since in this position the anatomical relations are more easily 
remembered, asepsis can be more thoroughly maintained, and the after- 
coming head better managed. Moreover, in easy versions, it answers 
every purpose. If, however, difficulty is experienced in securing a knee 



612 OBSTETRIC SURGERY 

or foot, it may often be overcome by turning the patient upon the side. Of 
this I shall have more to say directly. 

The knees may be held by legholders, but if two reliable nurses or 
bystanders can be secured it is better to have one hold each knee, since 
it may be necessary to put the patient in the Walcher position to facilitate 
the passage of the after-coming head, or to turn her upon the side. The 
Trendelenburg position is also occasionally useful, especially in those 
cases in which there is difficulty in dislodging the head at the pelvic brim. 
Nothing could be more illogical or unscientific than to adopt one position 
because traditional in some country or locality, and never deviate from it. 

Preliminary Dilatation of the Cervix. — Except in certain cases of 
placenta prsevia in which immediate delivery is not to be undertaken, 
complete dilatation of the cervix is an indispensable prerequisite to the 
operation. The advice sometimes given to wait for dilatation is futile. 
If version is indicated, dilatation is indicated. Indeed, in many cases, 
especially in malpresentation, dilatation will not occur, no matter how 
long one waits. 

The largest size de Ribes bag that can be introduced is inserted and 
moderate traction made, or, if haste is necessary, manual dilatation is 
employed. When the cervix has been fully dilated, that is, so that four 
fingers can be introduced and separated, the fingers should be held in this 
position for a few moments, and the cervdx allowed to contract upon them. 
Thus one not only dilates, but paralyzes, the cervix, and prevents recon- 
traction. It should never be forgotten that an artificially dilated cervix 
has a tendency to recontract. The importance of thorough dilatation and 
paralysis of the cervix as a preliminary to version cannot be overestimated. 
Thus we prevent, or at least minimize, the danger of bad cervical tears. 
The cervix is not likely to be badly torn by a careful manual dilatation, but 
such a result is almost certain if the after-coming head is forcibly dragged 
through an imperfectly dilated cervix. Thus, too, we prevent a very 
embarrassing, and to the foetus most dangerous, complication, the grasping 
of the fetal neck by a recontracting cervix. If the foetus is to be delivered 
alive its passage through the cervix cannot be long delayed. Hence the 
too often forgotten fact that complete dilatation is even more important 
than in the forceps operation. 

Choice of Hand. — All things being in readiness, the hand correspond- 
ing to the position of the foetus, left position, left hand, and vice versa, 
or, in other words, the hand the palmar surface of which corresponds to 
the fetal abdomen, is well lubricated with lysol solution, and passed gently 
and carefully into the vagina, the fingers being so disposed as to form 
a cone, entrance being effected chiefly by backward pressure upon the 
perineum. Meanwhile the operator confirms his previous diagnosis of 
position and presentation, and notes carefully the size and shape of the 
pelvis and makes sure that the operation is really indicated. The mem- 
branes, if still intact, are ruptured3 and the hand is passed directly into the 



VERSION 



613 



sac. This is preferable to rupturing tlie membranes at a higher level, 
since there is less danger of infection when the hand is kept from direct 
contact with the uterine wall, and especially the placental site. The head 





?ISftj^^^"' 



.■rjii^^ 



Fig. 2.(>\ — Biminur \u 



in vertex presentation. Case of a multipara with flat pelvis. 



is gently raised and pushed to that side toward which the occiput points, 
counter-pressure being made by the external hand at the fundus. It is a 
cardinal rule, never to be forgotten, that, throughout the operation, the 
external hand at the fundus should guide and control the movements 



614 



OBSTETRIC SURGERY 



of the internal hand, thus preventing a dangerous strain upon the uterine 
attachments. As the head is pushed aside, the external hand presses the 
breech in the opposite direction, and as the internal hand passes upward, 
the operator observes whether the cord is pulsating regularly. In the 
case of a dead foetus the operation, unless it promises to be an easy one, 
should be suspended. During uterine contraction all manipulations should 




Fig. 365. — Bringing down foot the 



wrong wa3\ 



cease, and the fingers should be extended so that the hand will occupy 
as little space as possible. 

Finding a Knee or Foot. — On finding his hard in the uterine cavity 
the beginner is apt to be embarrassed by what appears to be a muhi- 
plicity of small parts. He will be much aided by remembering that, 
contrary to the advice usually given, the knee, not the foot (Fig. 365), 



VERSION 



615 



is in vertex presentations the objective point. The knee is usually on a 
lower level than the foot, and is more easily reached and recognized. This 
is well shown in Fig. 366. Note that the knee points down, while the 
elbow points up. When the knee is reached and recognized, simple traction 
causes extension of the leg, and the hand sliding down grasps the foot. 




Fig. 366. — Bringing down foot the right way. 

Many rules have been given for distinguishing a foot from a hand. 
In my opinion they are unnecessary. The heel, of course, is the peculiar 
mark of the foot, but it would seem that a man who, having in his grasp 
a fetal foot, could not tell it from a hand without specific rules, could not 
do so if he had the lost libraries of Alexandria at his disposal. 

It is better to seize only one foot, since we thus leave a larger mass to 



616 



OBSTETRIC SURGERY 



dilate and facilitate the passage of the after-coming head, and, in placenta 
prsevia, to act as a tampon. In difficult cases, however, e.g., in pelvic con- 
traction, it may be necessary to seize both feet. 

Choice of Kxee or Foot. — It is much better to seize the anterior knee 
or foot if possible. The novice will be glad to get either, and having 
found one would, perhaps, be unwise to let it go, but as soon as he has 
acquired some experience he will — except in certain cases of transverse 
presentation, to be considered later — do well to seek the anterior foot in 
every case. For this choice there are three reasons : 




Fig. 367. — Traction correctly made on anterior foot. 

1. Traction on the anterior foot promises forward rotation of the 
back (Fig. 367). 

2. When traction is made on the anterior foot, the Ime of traction corre- 
sponds more closely with the axis of the pelvic brim. 

3. In traction on the posterior foot, the anterior buttock may be caught 
behind the symphysis (Fig. 368). 

Moderate traction usually suffices to turn the child and carry the head 
to the fundus. Aversion, however, is not complete until the knee appears 
at the vulva. The young operator should avoid the mistake of thinking 
that the bringing down of a foot necessarily means the dislodgement of the 
head and the completion of the version proper. 

When is a version complete? Too often the beginner, and even the one 



VERSION 



617 



who ought to know better, takes it for granted that version is complete as 
soon as a foot appears at the vulva. It is quite possible to bring a foot to 
the vulva without dislodging the head from its original position. In this 
case the child has been simply doubled upon itself, and if the operator loses 
his head and attempts to extract the child by main force, much harm 
may be done. If he would be certain that version is complete he must 
deliver the leg as far as the knee. If this cannot be done without the use 
of force he should at once suspend the operation and determine the cause 
of delay. The treatment of this complication will be considered in a 
moment. In the meantime, let us remember version is not complete unless 




Fig. 368. — Traction is incorrectly made on posterior foot. 

the leg can be delivered as far as the knee. If this cannot be done without 
the use of force the operation should be at once suspended and the cause 
of delay determined (Fig. 369). 

As soon as the foot and leg have been delivered they should be wrapped 
in a warm sterile towel, and this also for three reasons : 

1. To maintain the bodily heat of the foetus. 

2. To prevent premature inspirations due to the reflex action of cold. 

3. Because the operator can make much more effective traction than 
when his hands grasp the slippery foot and leg of the foetus. 

Some teachers advise that when version is complete the danger has 
passed and extraction may be delayed. In my opinion this is a mistake. 
The foetus may already have been more or less asphyxiated, and delay will 
result in increased fetal mortality. Moreover, the mother is exposed to the 



618 



OBSTETRIC SURGERY 



added danger involved in a second anaesthesia and a second operation. 
Nor should we forget that, if we wait too long, the cervix may recontract. 
As soon as version has been completed the fetal heart should be auscul- 
tated, and, if signs of asphyxia are noted, delivery should be hastened. 





y 



I 



Fig. 369. — Bimanual version in vertex presentation. The hand in utero has brought down the anterior 
foot, which descends to the vulva while the other hand favors turning. 

This precaution, so often neglected, is of the greatest importance. It is 
the height of folly to subject the mother to such an operation as version 
in order to secure a living child, and at the same time to neglect our only 
means of knowing the condition of the child during the progress of the 
operation. 



VERSION 619 

Difficulties and Complications. — Now and then difficulty is found in 
displacing the vertex. Of course, if the head is wedged in the brim and 
cannot be moved by moderate force, the operation is contra-indicated, but 
such cases are rare. ]\Iore commonly, the child cannot be turned, the 
head refusing to ascend even after it has been pushed to one side and the 
foot brought down into the vagina. In these cases two fingers in the 
vagina, aided by the external hand, may succeed. Both feet may be 
brought down that more efficient traction may be secured. The Trendelen- 
burg position should be of service. The so-called combined method, by 
means of which the hand in the uterus pushes up the head while the foot 
is drawn down by a fillet, is obsolete and likely to lead to rupture of the 
uterus. 

In some cases it is difficult or impossible to reach a knee or foot. As 
noted above, this difficulty may often be overcome by turning the patient 
upon her side. This expedient should never be forgotten. In the course 
of a difficult version for shoulder presentation every effort with the patient 
in the dorsal position having failed, I was able to secure a foot and deliver 
a living child by having the patient turned upon her side. I recall another 
case in which the same measure was successful and was obviously the 
means of saving the life of a patient. Unavailing efforts had been made 
to extract a perforated head and the patient, who had been previously 
subjected to an hour's forceps traction, was in a condition of marked shock. 
Version was tried, but proved ineffectual until the patient was made to 
assume the lateral position. 

Vhile the change from the dorsal to the lateral position is being made, 
the hand may remain in situ. It is well to place the patient upon the side 
corresponding to the abdominal surface of the child and, if not successful, 
to turn her upon the other side. 

It is astonishing that so many students and practitioners are ignorant 
of this method, and that so many text-books make no mention of it 
whatever. 

Now and then the uterus becomes tetanically contracted about the 
foetus and even the introduction of the hand is difficult. In these cases 
full anaesthesia is of special importance. Efforts to pass the hand into the 
uterus should be tentative, and upward pressure intermittent and gradual. 

If, after passing the head, the hand encounters the contraction ring, the 
greatest caution is indicated. The presence of the ring at this height indi- 
cates great stretching and thinning of the lovv^er uterine segment and, 
consequently, imminent danger of uterine rupture. If the first cautious 
attempts are unsuccessful, it is the part of wisdom to desist, and to adopt 
some other method of delivery. 

Version being complete, we have to consider what is ordinarily called 
breech extraction, although it might as well be called footling extraction. 
Except in rare cases of abnormality, the breech or trunk ofifers no resist- 
ance, difficulty being encountered only in the delivery of the arms, and of 



620 



OBSTETRIC SURGERY 



the after-coming head. It is an essential part of the operation of podalic 
version, taken as a whole, and also, of course, of practically all kinds of 
internal or combined version, as well as of all breech presentations. It 
is one of the most important, and one of the most generally misunderstood, 
operations in midwifery, and deserves separate and careful consideration. 

Breech Extraction 
The patient should always be in the lithotomy position, with the hips 
well over the edge of the table, in order to permit that downward and 



/ 




Fig. 370. — Grasping the thighs and buttocks during extraction. 



backward traction upon the foetus which is an essential part of the opera- 
tion. When the knee appears at the vulva, it should be wrapped in a warm 
sterile towel. A short period of delay may now be granted in order to 
allow the gradual dilatation of the cervix by the half-breech, provided the 
fetal heart-sounds are approximately normal, but if there are evidences of 
impending asphyxia, delivery must be hastened. This auscultation of the 
fetal heart should never he neglected. The foot and leg constitute a con- 
venient handle for traction, which should be made downward and backward 
in the axis of the pelvic brim. As soon as practicable, however, the grasp 
should be transferred from the legs to the thighs and buttocks (Fig. 370). 



VERSION 



621 



One should avoid seizing the abdomen or testicles, as serious injury has 
been done in this way. It is highly important at this stage that the operator 
should guard against posterior rotation of the back, an unfortunate accident 
which is always due to inefficiency or neglect. Anterior rotation may be 
effected by gently rotating the hips or by making traction on one leg or the 




y 



.,11/'^^ 



^ 



Fig. 



371. — Podalic version. Release of the posterior arm. 



Other, according to the position. Much force is never necessary. 

Delivery of the Extended Arms.— With the birth of the breech begins 
the period of greatest danger to the foetus, since from now on we can 
hardly expect to escape the evil consequences of pressure upon the cord. 
If the latter is put on the stretch, it should be gently drawn down ; and 
if caught between the legs of the foetus, it should be disengaged. As'soon 



622 OBSTETRIC SURGERY 

as the fetal scapula appears at the vulva, the position of the arms should 
be noted. In uncomplicated breech presentations, the arms may remain 
folded upon the chest, entering the cavity of the pelvis with the fetal thorax 
and being easily drawn down by a finger in the vagina ; but in many breech 
cases, and practically always in version, they become extended as the result 
of traction. Unless the child is premature or very small, the head and 
extended arms cannot pass the pelvic brim at the same time. The prompt 
release of the arms, therefore, becomes an important duty of the 
accoucheur. 

As a rule, the posterior arm can be more easily reached, since there is 
more available space in the hollow of the sacrum. The first step, and this 
is very important, is to pull the fetal trunk strongly downward in the axis 
of the brim, i.e., toward the floor. The object of this manoeuvre is to make 
the shoulder more accessible. The feet of the child are then seized and 
carried strongly upward. In this way the body is made to hug the anterior 
vaginal wall, giving the greatest possible space posteriorly and bringing 
the posterior arm well within reach. The operator then follows the fetal 
back with the disengaged hand, as shown in Fig. 371, until it reaches the 
posterior shoulder. From this point of vantage he passes the fingers along 
the arm until he secures sufficient purchase to sweep it downward and 
forward across the chest. It is well, of course, to reach the elbow joint 
if one can, but this is not always possible and the time at one's disposal 
is limited. Sometimes the risk of a fractured humerus must be accepted. 
The injury heals readily and, as Bumm says, a living child with a broken 
arm is better than a dead child with the arm uninjured. 

For the release of the second arm the trunk is rotated until the arm 
becomes posterior. It is then released, as already described. 

Another method of releasing the anterior arm is to carry the feet 
directly downward, i.e., toward the floor, and passing the fingers behind 
the symphysis to the shoulder and arm, as shown in Fig. 372. 

In my experience the first of these methods is, except in easy cases, the 
more prompt and efficient. 

Frequently the release of the arms proves a difficult matter. The cause 
■ of the difficulty is usually disproportion in size between the head and the 
pelvis, usually a large head, more rarely, a moderately contracted pelvis. 
Sometimes the head and extended arms have become jammed together in 
the pelvic brim, and something may be gained by pushing the foetus upward. 
Far more often, however, in my experience, the operator has attempted to 
release the arms before they were really within reach, and drawing the 
trunk strongly downward in the axis of the brim and then upward and 
backward will enable him to succeed. Since I have appreciated this fact 
I have found the task much easier, and I would strongly urge it upon the 
attention of the practitioner. 

Now and then, for some unexplained reason, It Is easier to bring down 
the anterior arm first. I recently met with a case In which, with two 



VERSION 



623 



fingers in the vagina, I easily brought down the anterior arm, although 
I had failed to reach the posterior. Sometimes, again, one will succeed 
by passing the fingers along the anterior surface (abdomen and chest) of 
the fcetus, instead of the back. Now and then an arm will be found behind 
the neck of the foetus, preventing the occiput from entering the pelvis. 
It can usually be brought down by first rotating the foetus in such a manner 





Ui^ 



Fig. 3/ 



-Podalic version. Release of anterior arm. It is usually better to rotate the foetus until 
the anterior arm becomes posterior and then release it as described. 



that the impaction may be released, e.g., if it is the left arm, rotate to the 
left, and vice versa. This carries the arm to the hollow of the sacrum, 
where it can be most easily reached. 

These expedients may be quickly tried one after another, but as a 
general rule it is unwise to lose such precious time in experimenting with 
methods of doubtful efficacy. In some cases the only certain way of releas- 
ing the arms, if release is possible, is by passing the whole hand into the 



624 



OBSTETRIC SURGERY 



vagina. With the hand in the vagina and two fingers in the lov^er segment, 
the cause of delay is at once apparent, and set rules of procedure only 
tend to confuse a situation already clear. It must be admitted that this 
method subjects the perineum to a severe strain and may result in a bad 
tear, which should, of course, be carefully repaired, but the mother will 
forgive her physician for this if he secures for her a living child. 



/ 



Delivery of the After-com- 
ing Head. — The Combined 
AIethod. — The arms having 
been brought down, it remains to 
deliver the head. If this is in the 
cavity of the pelvis, its delivery 
is usually an easy matter, but 
if its greatest circumference re- 
mains above the brim, much 
difficulty may be experienced. 
Alany methods of delivering the 
after-coming head are described 
in the text-books. Most of them 
are of historical interest only. 
To discuss them all would but 
lead to confusion. I will here 
consider but three, the method 
of Mauriceau, which is applica- 
ble only to cases in which the 
head has passed the pelvic brim ; 
the combined method, which in- 
cludes not only traction upon the 
fetal body from below, but pres- 
sure upon the after-coming head 
through the abdominal wall; 
and the method of de Ribes. 
The combined method is usually 
regarded as applicable only to 
cases In which the head is above 
the brim, but in my opinion it is 
the quickest and best way out 

Fig. 373.-Wigand-Martin-Winckel combined method ^f ^J^^ difficulty lu mOSt CaSCS 

whatever the position of the head and it will therefore be first described. 
The patient remains in the lithotomy position, with the hips well over 
the edge of the table. As soon as the arms have been delivered, two 
fingers are passed into the vagina and inserted into the child's mouth, just 
sufficient pressure being made upon the lower jaw to keep the chin at the 
breast, and thus maintain flexion of the head. The jaw is not to be used, 
however, as a traction handle, since serious injuries might be inflicted. 




VERSION 



625 



The child rides astride the forearm of the operator, or, better, the feet are 
held by an assistant, while the operator with his external hand presses 
the head into and through the brim of the pelvis (Fig. 373). 

The beginner is almost sure to make the mistake of pushing the head 
fonvard against the symphysis. When the greatest circumference of the 
head has not passed the brim, pressure should be made directly downward 
(toward the floor). Often the head slips through with a jerk or crack, 




Fig. 374. — Manoeuvre of Mauriceau. 

which causes the inexperienced operator to fear that he has inflicted some 
injury upon mother or child. But this is seldom the case. When the head 
has passed the brim, pressure is made in a more horizontal direction, and 
as the occiput appears under the pubic arch the fetal trunk is brought 
upward and backward, while the face, brow and vertex sweep over the 
perineum. This method of delivery can be used whether the head is 
above the brim or in the cavity of the pelvis, as I have often demonstrated. 
4C 



626 



OBSTETRIC SURGERY 



I believe that one who has learned it well will seldom be obliged to resort 
to the forceps for the delivery of the after-coming head. 

In cases of great difficuUy the Walcher position may be tried. Since 




Fig. 375. — Method of Mauriceau. 



the patient is already in the dorsal position, with the hips well over the 
edge of the table, the assumption of this position involves neither difficulty 
nor delay. 

One often sees an anxious attendant pulling upon the child's feet. 



VERSION 



627 



Such traction does no good. Indeed, by favornig extension of arms and 
head it is productive of much harm. The practitioner wU do we 1 to 
remember that anv nurse or bystander can hold the feet up and out of his 




Fig. 376. — Extraction of the head. Manoeuvre of Champaicr de Ribes. 

way. The things that are essential, the flexion of the fetal head by the 
fingers in the mouth, and the forcing of the head through the pelvic brim by 
external pressure, only he can perform. 



628 



OBSTETRIC SURGERY 



Mauriceau's Method. — In the method of Mauriceau, as in the com- 
bined method, the child rides astride the forearm of the operator and the 
head is flexed by the fingers in the mouth. The right hand, however, 
instead of making pressure upon the head externally, is used for traction 
on the fetal shoulders (Fig. 374)- This traction is at first downward, 
but when the occiput appears beneath the symphysis, the body of the child 
IS carried upward and backward, as in the combined method, the face 
sweeping over the perineum (Fig. 375)- 

I^Iethod of Champetier de Ribes.— In very obstinate cases the 
manoeuvre of de Ribes may be tried. I have, on several occasions, found 
this very effective. It is a combination of the two methods already 




Fig. 377. — Prague manoeuvre in posterior position of the after-coming head. 

described, and requires the presence of an assistant. The method of its 
employment is well shown in Fig. 376. 

Backward Rotation of the Occiput. — As above noted, the back of 
the foetus should always be guided to the front during the extraction of the 
breech. The careful operator will be on his guard during the delivery of 
the thighs and trunk, and should have no difiiculty in preventing posterior 
rotation. Should this precaution have been neglected, however, or should 
such rotation have occurred before his arrival, he should endeavor to rotate 
the occiput to the front. This is best accomplished by Edgar's method. 
Two fingers are placed in the child's mouth and the head flexed. With the 
other hand the shoulders are grasped by the thumb and third and fourth 
fingers, while the first and second fingers are placed one on each side of the 
occiput. This gives a very efficient control. If the head cannot be 



VERSION 629 

rotated, it must be extracted with the occiput posterior. The head is 
usually extended and the chin caught behind the symphysis. Well directed 
suprapubic pressure will usually force the head into the pelvic cavity, and 
extraction is completed by carrying the trunk strongly upward and for- 
ward over the mother's abdomen. This method exposes the child to much 
danger, since the neck is drawn forcibly against the symphysis, as shown 
in Fig. 377, and subjects the perineum to severe pressure. Danger to the 
child is best avoided by not carrying the body upward until the external 
hand has forced the head well down into the cavity of the pelvis. 

I cannot too strongly emphasize the fact that breech extraction is an 
operation of difficulty and importance. Once begun, it must be finished 
within a few moments, or the child will be lost. Here, if anywhere, it is 
literally true that the physician holds in his hands the keys of life and 
death. The beginner will do well frequently to rehearse this operation 
in all its details, to watch its performance when opportunity presents, and 
to secure, if possible, the advice of an experienced colleague at his first case. 

The Cervix as an Obstacle to Delivery. — Contraction of the cervix 
about the child's neck constitutes a very serious obstacle to delivery. As 
a rule, the condition does not involve any special danger to the mother, 
because if she is left alone the cervix will relax after a time and delivery 
occur spontaneously, but it is, of course, fatal to the child if relief is not 
afforded within a few moments. Traction upon the shoulders serves only 
to draw cervix and foetus to the vulva. If the child is living, multiple 
small incisions in the cervical margin may suffice to cause rapid dilatation. 
These incisions should be mere snips with the scissors, not more than one- 
half centimetre in length. In the meantime, an effort should be made, by 
means of two fingers passed within the cervix, to relieve the umbilical 
cord from pressure. 

This complication Is always evidence of improper technic In the per- 
formance of version, of neglect of complete dilatation and paralysis of the 
cervix. Deep Incisions are to be avoided, since they may extend so as to 
do incalculable harm. 

After all versions, the operator should be on his guard against post- 
partum hemorrhage. Sudden emptying of the uterus always predisposes 
to hemorrhage, and the profound narcosis necessary in version often 
causes uterine relaxation that Is long-continued and requires constant 
watchfulness. The careful physician will hardly be willing to leave his 
patient In less than two hours, and before taking his leave he will be sure 
to satisfy himself that the uterus Is well contracted. 

What has been said here refers to internal podalic version In head 
presentations. Internal version In transverse positions Is a subject by 
itself, and one which merits special consideration. In view of this fact, it 
is discussed in connection with the treatment of transverse positions, of 
which. Indeed, it forms the principal part. 



630 



OBSTETRIC SURGERY 



External Version 

In external version, as already stated, all manipulations are made 
through the abdominal wall. 

Indications. — External version is employed for the correction of 
transverse or breech presentation recognized before the beginning of labor, 
or, at all events, before rupture of the membranes, and engagement of the 
presenting part. The period of choice in breech presentation is the end 
of the eighth month before the engagement of the head and the formation 
of the lower uterine segment. 




Fig. 378. — External version. Photograph of an actual case. The foetus, of course, is "sketched in.* 



Contra-indications. — This operation is contra-indicated if the mem- 
branes have been ruptured, or if the head has descended into the pelvic 
cavity, in twin pregnancy, and if the foetus is dead. In hydramnion it is 
easy but useless. It is more difficult in primiparse, but by no means 
impossible. 

Advantages, Disadvantages. — External version has the great advan- 
tage of not exposing the mother to the danger of infection. It is said that 
it may cause the death of the foetus by pressure upon the cord, or even 



VERSION 631 

separation of the placenta. I have not observed these accidents, and am 
incHned to think that they are due to its employment in unsuitable cases, 
or to rough and unskilled manipulations. The chief disadvantage of 
external version is that it can usually only be performed before labor 
begins, and that the old position is likely to recur. This, however, is not 
always the case. Now and then one is gratified to find that in the case 
of an external version, performed weeks before labor, the normal position 
is maintained. 

Technic. — It is important that the bladder and rectum be empty. The 
patient should be in the dorsal position, with knees moderately flexed and 
head and shoulders slightly elevated. In this position the greatest relaxa- 
tion is secured. The position of the child must, of course, be accurately 
determined, and the more proficient the operator in the external exam- 
ination of pregnancy, the more likely he is to succeed. 

One hand appHed to the head of the foetus gently urges it in the 
direction of the pelvic brim, while the other pushes the breech in the 
opposite direction. It is obvious that the hands should be so applied as to 
flex both head and breech, thus favoring the natural attitude of the foetus, 
and at the same time making it as short as possible. This is well shown 
in Fig. 378. 

The operator should be satisfied with gradual and intermittent progress. 
AVhen he has succeeded in effecting a partial revolution of the foetus he 
should pause for a few moments, meanwhile holding the foetus in its newly- 
acquired position (Figs. 379 and 380). Manipulations, while persistent, 
should be gentle and should be suspended if a contraction comes on. Brute 
force is never justifiable. Pain should not be produced. Experience has 
taught me that much may be gained by talking to the patient in a reassur- 
ing way and by diverting her attention. This helps to prevent nervousness, 
involuntary resistance and spasmodic contraction of the abdominal muscles. 
In this way one often succeeds when least expecting it. When the head 
has been brought to the pelvic brim, it may be maintained in its new position 
by a pad, or sand-bag, on either side of the uterus, and a bandage. The 
patient meanwhile remains in bed in the dorsal position. This is manifestly 
impracticable if the version is done weeks before term. In these cases 
the patient should be allowed to get up and go about as usual, but should 
be directed to return in a week in order that the physician may see whether 
the new position has been maintained (Fig. 381). 

Version by the Combined or Bipolar Method of Braxton Hicks 

This method, as the name implies, is a combination of external and 
internal version. The hand is introduced into the vagina, but only two 
fingers are passed into the uterus. It is not adapted to head presentations 
at term when immediate delivery is indicated since, as we have already 
learned, version in such cases should be preceded by complete dilatation 





m 




VERSION 635 

As in the internal method, the version is complete when the knee is at 
the vulva. If the operation has been performed for placenta prsevia, or 
if the foetus is dead, only moderate traction is made — just enough to grad- 
ually •• tire out " the cerA'ical sphincter. x\t the same time the breech acts 
as a cen-ical tampon, or if for any reason immediate delivery is regarded 
as highly dangerous to the mother, only sufficient traction is made to 
maintain moderate pressure upon the resisting ring. This pressure serves 
to restrain hemorrhage if present, and is in itself a powerful excitant of 
uterine contractions. 

CEPHALIC VERSION 

External version is always cephalic. In transverse positions it would 
obviously be much more difficult to seize and bring down a head than a 
foot. \>r\- rarely cephalic version is indicated in the course of combined 
A-ersion. A typical case would be one in which the head is near the inlet, 
the membranes unruptured, or, at any rate, the foetus still freely movable, 
and immediate deliver}- not urgently indicated. 

Pelvic Aversion 

This variety of version is, of course, a matter of necessity, never of 
choice. For example, if in the attempt to rectify a transverse position 
of the foetus the operator finds that he can neither reach a foot nor bring 
the head to the brim, it is obviously better to bring down the breech, if 
this be possible, than to leave the transverse position uncorrected. 



CHAPTER XXIX 
THE CESAREAN SECTION 

The term '' Csesarean Section " means the extraction of the foetus 
through an opening in the abdominal wall and uterus. 

Historical. — The operation, as originally performed, dates from high 
antiquity. There is a classic legend to the effect that Julius Caesar was 
'' from his mother's womb untimely ripped." Whether this be true or not, 
the story has survived to give a name to abdominal section for the removal 
of the foetus. In Germany the term KaiserscJinitt serves well to typify 
what may well be called the imperial operation — the capital operation of all 
surgery. 

Until 1876 the mortality was over 50 per cent. Before that time it was 
the custom to leave the uterine incision unclosed. This procedure, which 
seems incomprehensible to us now, permitted free bleeding and favored 
the transmission of infection from the uterine cavity to the peritoneum. 

In 1876 Porro conceived the idea of eliminating these dangers by 
removing the uterus. This considerably reduced the mortality. At first, 
the uterine stump was sewed into the lower angle of the wound and treated 
extraperitoneally. Later, the development of modern aseptic technic made 
it possible to suture the stump and drop it back into the abdominal cavity. 

The third epoch in the history of this operation dates from 1882, when 
Sanger showed that by exact suture of the uterine wound the dangers of 
hemorrhage and infection could be minimized, and the removal of the 
uterus with its attendant disadvantages made unnecessary. 

Davis, of X'ew York, in 1904 introduced the small high incision partly 
above the umbilicus, in my opinion the most important advance in technic 
since the time of Sanger. Davis later in the same year made the incision 
entirely above the umbilicus. 

Indications — An indication for the Csesarean section may be either 
relative or absolute. These terms are best defined by illustration. 

In certain cases it is impossible to remove the foetus, except by the 
Caesarean section. For example, when the true conjugate is less than 
5^ to 6 centimetres it is mechanically impossible to remove per vaginam 
a foetus of average size. Even a dead foetus would have to be removed by 
abdominal section. Its slow dismemberment and removal, occupying 
hours, would be far more dangerous than the Csesarean section. Here 
the indication is absolute. There is no question of doubt or choice. 

Another example of absolute indication is to be found in the case of 
an irremovable tumor blocking the pelvic canal. 

But there is a class of cases in which it is dif^cult to tell in advance 
whether the Caesarean section is really necessary. These are the cases in 
636 



THE CESAREAN SECTION 637 

which some other method of delivery is mechanically possible — cases in 
which the true conjugate is from 5^ or 6 to 9 centimetres. These are 
the doubtful cases. The indication is not absolute but relative. The 
Caesarean section comes into competition with a long series of operative 
procedures — symphysiotomy, pubiotomy, craniotomy, forceps and version. 
Now and then, as Qxery hospital interne knows, the case may be unex- 
pectedly terminated by an easy delivery, no assistance whatever being 
required. 

These have well been called the border-line cases. Their proper treat- 
ment constitutes perhaps the most difficult problem in obstetrics. It is 
considered in connection with the treatment of contracted pelvis. Of 
course the nearer the lower limit is approached, the more the Csesarean 
section comes into consideration, and I believe that it will soon displace 
both symphysiotomy and pubiotomy, always more or less experimental, 
though there may now and then be a case in which the latter operation 
is justifiable. 

There has been of late a disposition to extend widely the indications 
for the Csesarean section, and to practise it in eclampsia, placenta prsevia, 
prolapse of the cord, and other conditions in which its employment was, 
until now, never considered. This subject will be taken up in connection 
with the various complications of labor. Reading between the lines, it is 
easy to see that many of these operations were performed by surgeons and 
g}'n3ecologists with little obstetric experience, and might have been avoided. 
We cannot, however, doubt their occasional justifiability. 

Of course, the Csesarean section should not be performed if the child 
is dead or non-viable, and especial care should be taken that the foetus is 
not premature. For this reason it is better, as will be explained presently, 
to postpone the operation until labor has begun. 

Prognosis. — Before the reforms of Sanger, who was the first to 
appreciate the great importance of exact suture of the uterine incision, 
the mortality was fifty per cent, or more, so high indeed that the operation 
was undertaken only as a last resort, in cases of absolute indication. Since 
his time, however, the prognosis has steadily improved. In a general way 
it may now be said that, under favorable circumstances, the mortality is 
from three to five per cent., though many experienced and careful operators 
have had long lists of cases with no mortality. Veit, indeed, goes so far as 
to say that the operation is without danger. This opinion will hardly be 
shared by the majority of operators. 

Previous attempts at delivery, and frequent examinations, especially by 
those whose asepsis is questionable, render the prognosis much more 
serious. The existence of infection already present is of course extremely 
unfavorable, and if under such circumstances an abdominal section appears 
unavoidable, it is probably better to remove the uterus. 

Time for Operation. — Some writers advise that the operation be per- 
formed at an appointed time before the beginning of labor. This is, of 



638 OBSTETRIC SURGERY 

course, more convenient for all concerned, but in my opinion it does not 
conserve the interests of the patient. It is far better to wait until she has 
had several hours of good labor pains, and this for two reasons. 

In the first place, one thus avoids the possibility, or at least the responsi- 
bility, of delivering a premature child. I recall a case in which a well- 
known g}'n3ecologist delivered a non-viable foetus at an elective operation. 
Dr. Asa B. Davis relates a case in which an elective Csesarean section was 
performed and a premature child delivered, after several experienced 
consultants had decided that the patient was at term. 

Nor is such a case as improbable as at first sight it might seem. It is 
not always easy to determine the exact period of pregnancy, especially if 
the patient is a primipara, and the menstrual history doubtful. It is not 
pleasant to find that one has subjected a mother to an abdominal section 
for the sake of delivering a dead or non-viable foetus. 

In the second place, by practising the late operation one avoids the 
danger of hemorrhage from uterine atony, a dangerous complication of 
which I shall have more to say presently. A uterus that has been con- 
tracting strongly and regularly for several hours will continue to contract 
after the abdomen has been opened. 

An additional reason is to be found in the fact that there are many 
border-line cases in which it is hardly fair to the patient to operate without 
first giving her the benefit of the test of labor. 

Preparations. — It was formerly thought necessary to dilate the cervix 
before operating in order to secure drainage. Abundant experience has 
shown this to be unnecessary, even in cases that are operated upon before 
labor begins. Moreover, it is obvious that this procedure markedly 
increases the danger of infection. 

I have not practised preliminary douching of the vagina, believing that 
it reduces the normal safeguards against infection and is, to say the least, 
quite unnecessary. Nor have I had reason to regret its omission. 

Twenty minutes before the operation is begun, the patient should 
receive a hypodermatic injection of some suitable preparation of ergot. 
There can be no valid objection to this, and it aids materially in reducing 
the probability of hemorrhage from uterine atony — the only immediate 
danger that attends the operation. 

As a final preliminary the bladder is emptied. This is a precaution tnat 
should never be omitted. A full bladder not only prevents uterine con- 
traction, but may itself be in the track of the knife. 

Ether oxygen should be the anaesthetic. A maximum of oxygen and a 
minimum of ether. It is wise, whenever possible, to secure the ser^aces of 
a skilled anaesthetist, who will know how to " keep the patient under " 
with as little of the anaesthetic as possible, thus minimizing postoperative 
nausea and vomiting, and lessening the danger of fetal asphyxia. Chloro- 
form increases uterine relaxation and predisposes to hemorrhage. Nitrous 
oxide gas rapidly asphyxiates the foetus. 



THE CESAREAN SECTION 639 

Technic. — The importance of the most scrupulous observance of the 
rules of asepsis cannot be overestimated. Most of the deaths are the result 
of peritonitis. The iodine method of disinfecting the abdominal surface- 
has simplified the matter of preparation, and is of the greatest possible 
advantage in emergency cases. The whole abdomen is thoroughly painted 
with tincture of iodine, two or three coats being applied, without previous 
washing. If, however, water has been applied to the surface within eight- 
hours, the abdomen should be thoroughly scrubbed with ether and then 
with alcohol, before the application of the iodine. Gross visible contam- 
ination, if present, should first be removed by scrubbing with alcohol. 

The operator and his assistants should wear sterile gowns and rubber 
gloves, and the entire body of the patient, except the field of operation, 
should be covered with sterile sheets or towels. 

It is of the greatest possible importance that the patient be uninfected 
at the beginning of the operation. Hence, in all doubtful cases, internal 
examinations should be avoided as far as possible, and as soon as the 
operation has been definitely decided upon, they should be absolutely 
forbidden. 

But few instruments and appliances are needed. Among these are a 
scalpel, a pair of blunt-pointed scissors, needles, needleholder, thumb 
forceps, artery clamps, the usual sterile dressings, and, above all, reliable 
suture material. 

Four assistants are desirable. One to act as first assistant, another to^ 
pass instruments and ligatures, a third to receive and attend to the child, 
and a fourth to give the anaesthetic. A resourceful man will be able to 
dispense with one or even two of these assistants, especially if a good 
nurse is in attendance. 

Shall the uterus be delivered through the abdominal incision before 
the removal of the child? This was formerly the universal custom, and 
is still the general practice of many teachers and operators. I think the 
question should be answered as follows : The delivery of the uterus makes 
necessary a somewhat longer incision, and the exposure of so large a viscus 
probably slightly increases the danger of shock. The operation, however, 
is somewhat easier, and there is considerably less danger of contamination 
of the general peritoneal cavity by the uterine contents, for by delivering 
the uterus from the abdominal cavity, provisionally closing the upper part 
of the abdominal incision, and carefully surrounding the parts with gauze 
pads, the escape of the uterine contents may be efifectually prevented. This 
fact has been well emphasized and illustrated by Veit, who reports forty 
cases treated in this way without mortality, although many of the patients 
had been long in labor. 

The delivery of the uterus through the abdominal incision then is to be 
preferred. 

I. In the case of an operator of small experience called upon to operate 
in an emergency. 



640 OBSTETRIC SURGERY 

2. In cases in which because of the long duration of labor, or for some 
other good reason, the operator does not feel overconfident of the asepsis 
of the uterine contents. 

It is quite plain that no description of the operation is complete unless 
the technic of both methods is given. 

The incision formerly practised extended from the umbilicus to the 
symphysis. Strangely enough there are still some who not only practise 
but even teach this method. Such an incision may injure the bladder, which 
during pregnancy is, by its attachment to the anterior uterine wall, often 
drawn far above the symphysis. jMoreover, such an incision is much longer 
than is necessary, and is more likely to result in adhesions between the 
uterus and abdominal wall than one higher placed. Nor does it give access 
to the upper part of the uterus, where, as we shall presently see, the uterine 
incision should be made. The low incision, however, is obviously to be 
preferred if the Csesarean is to be followed by hysterectomy. If the uterus 
is to be delivered, the incision must of course be longer than if it is to be 
incised in situ. 

The length and position of the incision then depend altogether upon 
the character of the proposed operation. 

Let us assume that the uterus is to be delivered. An incision from 
12 to 1 6 centimetres is made at the left of the umbilicus, and with the latter 
as its middle point. The length of the incision will depend upon the size 
of the uterus and its contained foetus, and it is better to make the shorter 
incision at first, lengthening it later if necessary. The abdominal wall is 
very thin in advanced pregnancy and the incision should be cautiously 
made, the operator recalling the possibility of bladder or loops of intestine 
in front of the uterus, or, if a previous laparotomy has been done, of 
adhesions. Spectacular haste is out of place here. More than once I have 
seen an incautious operator cut into the uterus at the first stroke. It is wise 
to '' buttonhole " the abdominal wall and prolong the incision with the 
scissors, using the finger as a guide. 

The thinned and atrophied tissues bleed but little and no clamps m.ay be 
required. The blue-gray surface of the uterus shining through the filmy 
transparency of the peritoneum makes, upon the man doing his first 
Csesarean section, an impression never to be forgotten. The abdominal 
■ wall stretches easily in advanced pregnancy, and a finger hooked into each 
end of the cut converts an incision which at first seemed too short into one 
of sufficient length. 

One hand brings the fundus through the incision. This is very mate- 
rially aided by having an assistant make pressure alternately upon the 
sides of the uterus through the abdominal wall. The upper part of the 
incision is then provisionally closed by two or three sutures of silkworm 
gut and sterile gauze is packed about the uterus, both these measures being 
designed to keep the uterine contents out of the peritoneal cavity. The 
Trendelenburg position aids materially in this respect. 



I 



THE CESAREAN SECTION 



641 



It is true that bacteria can be demonstrated upon the surface of the 
uterus. Their presence is the result of the overflow of the uterine contents. 
But, as \'eit pertinently remarks, if they find no medium in the peritoneal 
cavity on which to grow, they are harmless. 

The incision in the uterus must be large enough to admit the hand. 
Here again it is better to make a buttonhole incision and prolong it with the 
scissors, thus avoiding the danger of injuring the foetus. It should be a 
high one, beginning at the fundus and extending directly downward only 
as far as is necessary and it should be exactly in the median line ( Fig. 383) . 

By limiting the incision to the upper part of the uterus one avoids 
the lower non-contractile, vascular portion, as well as the region of the 
bladder, and by keeping it in the median line one avoids the larger branches 




Fig. 383. — Csesarean operation. High incision in median line. 

of the uterine arteries. The operator should recall the usual right obliquity 
of the uterus and not make the incision too far to the left. 

If the placenta lies immediately beneath the incision, as it often does, 
no time should be lost in attempting to separate it, but the hand should be 
passed directly through it, as in central placenta prsevia. The child should 
be seized by the foot and extracted, as in Mauriceau's method, head flexed, 
and back toward the mother's feet. It is better to extend the incision a 
little, if necessary, than to risk tearing the uterus. An assistant now cuts 
the cord between two clamps and takes charge of the child. Do not worry 
if the child does not cry at once. A slight delay in the establishment 
of respiration is a physiological peculiarity of the Csesarean section, and 
is due to the suddenness of the change from intra-uterine to extra-uterine 
conditions (Fig. 384). 

The placenta and membranes are now removed. Special care should 
41 



642 



OBSTETRIC SURGERY 



be taken that the removal of the membranes is complete, especially in the 
lower uterine segrment. where thev are often adherent at this time. In 
these cases it is made much easier by wrapping the finger in gauze. 

During the opening of the uterus and the removal of the foetus hemor- 
rhage may be profuse, but the operator should not allow this to disconcert 
him. At this time sutures and sponges are as useless as they would be in a 
case of placenta previa. As in the latter condition, the bleeding will not 
cease until the uterus contracts and the uterus cannot contract until it is 
emptv. The best way to stop the hemorrhage is to empty the uterus 
without delay. 

When the foetus and placenta have been removed, the uterus contracts, 
and the bleeding from the placental site ceases, though there may still be 
considerable oozinof from the cut surfaces in the uterus. This ceases as 




ugn mcision. 



the incision is sutured. Proceed then as rapidly as is consistent with careful 
work. It was formerly thought necessary to constrict the cervix with 
a rubber band, or to have it compressed by the hands of an assistant, but 
this has been shown to be quite unnecessar}-. ^Moreover, it shuts oft the 
blood supply of the foetus, and predisposes to atony of the uterus. ^lassage 
of the uterus and the pouring of hot saline solution into its cavity almost 
always suffice to bring about contraction. Cragin has noted that in cases 
of obstinate relaxation the uterus contracts better if it is returned to its 
usual position and the suturing completed within the abdominal cavity. 
Obstinate and uncontrollable relaxation demands the removal of the 
uterus. This complication, however, is extremely rare and in my experi- 
ence can always be prevented by operating at the proper time, i.e., during 
the first stage of labor, and by giving a hypodermatic injection of ergot 
twenty minutes before the operation. 

Now comes the suture of the uterine wound — the most important part 



THE ct:sareax section 



643 



of the operation. The sutures may be either interrupted or continuous. 
]\Iany writers advise the former, but after trying both methods I am con- 
vinced that a continuous suture in three layers aftords a much more secure 
closure of the wound and is attended by less bleeding. Perhaps the inter- 
rupted suture is a little easier, but I have not found this to be the case. I 
use two layers of chromic gut, medium size, in the uterine wall, and one 
superficial layer of fine chromic gut to unite the uterine peritoneum (Fig. 
S^S^. The first layer unites the deeper part of the incision in the uterine 
wall. The operator should be careful not to enter the cavity of the uterus, 

Fig. 385. Fig. 386. 









*i 1. ->- 




Fig. 385. — Csesarean operation. First layer of sutures. 
Fig. 386. — Caesarean operation. Secondlayer of sutures. 

nor to include the decidua, since infection might thus be transmitted and 
rapid union prevented. The second layer unites the outer half of the 
uterine wall, while the third suture of fine gut includes the peritoneum only 
(Fig. 386). Some operators unite the peritoneum by a Lembert suture, 
but this takes time and has been shown to be unnecessary. The accom- 
panying illustrations show the best method of closing the uterine wound. 
Fig. 387 shows how the assistant should hold the uterus while the 
sutures are being placed. This method freely exposes the tissues to be 
sutured and enables the operator to work to better advantage. It also 
helps to prevent hemorrhage. 



644 



OBSTETRIC SURGERY 



The peritoneum and fascia are closed by continuous suture with 
chromic gut (Fig. 388). The skin edges are then united by sutures of 
silkworm gut. 

Following Fritsch various operators have made the uterine incision 
across the fundus instead of in the anterior wall. Recently A^eit has 
adopted this method in a long series of cases with good results. It is only 
adapted to cases in which the uterus is delivered through the abdominal 
incision, and, as A'eit himself admits, is probably no more effectual in pre- 
venting contamination of the peritoneal cavity than is the high anterior 
incision. It has been claimed by the advocates of the fundal incision that 
it is less likely to result in adhesions between the uterus and abdominal 




Fig. 387. — Caesarean cperation. Uterus held by assistant for placing of sutures. 

wall, but it would seem, as Williams remarks, that this is more than 
counterbalanced by the danger of intestinal adhesions in the fundal incision, 
and by the transmission of infection should it occur to the peritoneal cavity. 
Let us now consider a case in which the uterus is not to be delivered 
until after the extraction of the foetus. Here the incision is shorter, 8 to 
10 centimetres in length. It is more convenient to make the incision to the 
right of the umbilicus, since it is more apt to coincide with the middle line 
of the uterus and in this way the assistant is not obliged to rotate the 
uterus. Experience shows that the gauze pads formerly used can be dis- 
pensed with. Contamination of the peritoneal cavity is best prevented by 
having the assistant keep the abdominal walls in close contact with the 
uterus while the incision is being made and while the uterus is being 
delivered after the removal of the foetus. 



THE CESAREAN SECTION 



645 



This operation is best restricted to uninfected cases in the hands of 
operators of some experience ; but with these limitations it gives excellent 
results. Operative shock is minimized, hernia prevented, and the resulting 
scar is insignificant. 

With the removal of the fcetus and placenta, the uterus, now greatly- 
reduced in size, is brought out through the abdominal incision where it can 
be carefully walled oft, and conveniently and exactly sutured in the manner 
already described. 

Davis, in 1904, practised for the first time the small, high, median 
incision above the umbilicus. The advantages claimed for it are the follow- 
ing : " The abdominal wall at this point, in the full term woman, is thin 
and stretches easily. The small, 
high incision does not allow easy . , 

exposure or escape of the abdomi- 
nal contents. Xot infrequently, all 
that we see is the uterus and a 
small portion of omentum. This 
wound is away from the site of 
greatest strain upon the abdomi- 
nal wall, at a point reinforced by 
the recti muscles as they approach 
each other toward their upper 
attachments. It is small. We 
have never seen hernia follow- 
ing it. The liability to adhesion 
between the abdominal wound 
and the uterine wound is greatly 
diminished." 

After-treatment. — The after- 
treatment does not differ materi- 
ally from that of laparotomy in 
general. Recalling the importance 




/ 



Fig. 35 



. — Csesarean operation. Suturing the skin- 
edges with silkworm gut. 



of prompt and secure union of the uterine incision, the patient should be 
kept quiet for at least two weeks. Severe pain and, in particular, vomiting 
and retching, so common after operations, are highly undesirable at this 
time and should be promptly suppressed by the hypodermatic administra- 
tion of pantopon or morphine. A tight bandage is out of place. It proba- 
bly promotes the formation of adhesions between the uterus and abdominal 
wall. According to DeLee it may also cause ileus and dilatation of the 
stomach. Other things being equal, the patient should not only be allowed, 
but encouraged, to nurse her child. This promotes uterine contraction 
and aids involution. 

Technically the Csesarean section is not a very difficult operation. The 
chief difficulty is to determine whether it is indicated in a given case. This 
is often a difficult problem, though with the steady improvement in the 



646 OBSTETRIC SURGERY 

techiiic and results of the operation the decision does not involve as serious 
a responsibility as formerly. 

I would sum up the salient points as follows : 

The operation should be performed as near the time of labor as possible, 
preferably not until after the beginning of labor. 

The strictest asepsis should be observed and all vaginal examinations 
or manipulations not absolutely necessary for diagnosis should be 
prohibited. 

A full dose of ergot should be given hypodermatically twenty minutes 
before the expected operation. 

The length and location of the abdominal incision depend altogether 
upon the circumstances of the individual case. 

The uterine incision should be carefully and exactly sutured, the con- 
tinuous suture being preferable. 

Whenever the patient has been long in labor the uterus should be 
delivered through the abdominal incision and carefully walled off from 
the peritoneal cavity before the uterine incision is made. 

The Porro Operation 

When the removal of the foetus is followed by the removal of the uterus, 
the procedure is commonly known as the Porro operation. Of this we 
have already spoken. 

The original operation of Porro, in which the stump was sewed into the 
lower part of the wound, has been practically superseded by the modern 
method of supravaginal hysterectomy, i.e., amputation of the uterus above 
the cerA^ix, with closure of the abdominal wound. 

This operation, the study of which is very generally neglected, should 
be familiar to every one who does much obstetric work, since an emergency 
requiring its performance may arise at any time, e.g., in the case of rupture 
of the uterus, or of uncontrollable hemorrhage during the Caesarean section. 
Such emergencies, it is true, are not common, but do occasionally occur. 

Then, too, the operation is not so difficult that anyone of fair surgical 
training need shrink from its performance, since owing to the serous infil- 
tration of the pelvic structures the uterus can be lifted up until the struc- 
tures to be sutured and ligated are in plain view. 

Indications. — The Porro operation is indicated when there is a proba- 
bility that the uterine contents are infected, in certain cases of uterine atony, 
in certain cases of tumor formation, e.g., in carcinoma, or in extensive 
fibroid degeneration, and in certain cases of rupture of the uterus. Finally, 
it has been used as a means of sterilization in cases in which it was deemed 
unwise for the patient to undergo the risk of subsequent pregnancies. 

Technic. — Since there is, of course, no danger of hemorrhage from 
uterine atony in this operation there is more justification for choosing a 
convenient time before labor begins than in the case of the Csesarean section. 
But the operator should satisfy himself that he is not dealing with a 



THE CESAREAN SECTION 647 

premature child, and if there is the sHghtest doubt about this, the operation 
should be delayed. A'ery often, however, it is an emergency measure and 
must be done at once. 

The student is usually told that until the foetus has been removed from 
the uterus the technic of the operation is the same as in the case of the 
conservative C?esarean section. A moment's reflection will show that this 
is not the case, if the removal of the uterus has been decided upon in 
advance. In the latter case the incision is the same as that of any ordinary 
hysterectomy, i.e.^ chiefly, or altogether, below the umbilicus, and the 
higher incision suitable for the Csesarean section would obviously be out 
of place. 

After the foetus and placenta have been removed, the operator should 
waste no time in searching for the membranes, but should proceed at once 
to the removal of the uterus, leaving the ovaries, tubes and round liga- 
ments, unless there is some good reason for their removal. As infection 
is often suspected in these cases the abdominal cavity should be walled off 
zcitJi great care. For the same reason the incision is best made at the 
fundus, and with the patient in the Trendelenburg position. 

The ovarian arteries and the arteries of the round ligaments are 
ligated or clamped at some distance from the uterus, and a clamp is applied 
close to the uterus to prevent the anastomotic reflux of blood. The same 
process is repeated upon the other side, the broad ligaments are severed 
with the scissors, and an anterior peritoneal flap marked out just above the 
bladder, by the finger or by blunt dissection. 

AVe now come to the most important part of the operation, the ligature 
of the uterine arteries. The pulsations of the artery can usually be felt, 
although it may not be possible to isolate it completely, owing to the enor- 
mous varicosities of the broad ligaments that are so constant an accom- 
paniment of pregnancy. The artery should be ligated with great care, 
the uterus meanwhile being drawn to the opposite side, and the artery tied 
as near to the uterus as possible, leaving, however, space enough to prevent 
slipping, both these precautions in order to avoid the ureters. The uterus 
is now cut away, clamps and all, the anterior and posterior flaps united in 
such a way that no raw surfaces are left exposed, the cut surfaces in the 
broad ligaments united by a continuous suture and the abdomen closed in 
the usual manner. 

In total hysterectomy the cervix and upper part of the vagina are 
removed, and the upper end of the remaining portion of the vagina sutured 
with catgut. This operation has been advocated in cancer of the cervix 
complicating pregnancy, and in certain cases of infection. It is much more 
difficult, requires more time, and considerably increases the danger of 
shock. Its efficiency in cancer is a gynaecological question which need not 
be considered here. In cases of infection its advantages over the supra- 
vaginal operation are doubtful. It is certainly no operation for the general 
practitioner, and the specialist needs no instruction in its technic. 



648 



OBSTETRIC SURGERY 



The Original Porro Operation (Fig. 389) 
Here again the patient should be in the Trendelenburg position, and 
if the nature of the operation is already decided upon, the abdominal 
incision should be below the umbihcus. 

This operation, which has been generally abandoned because of the 
prolonged convalescence and the unsightly scar which follows, is neverthe- 
less occasionally justifiable as a measure of necessity, for example, in the 
case of a man inexperienced in abdominal surgery, and without the 
necessary assistance or surgical outfit for hysterectomy, as usually per- 
formed. Jeannin believes that owing to its simplicity, and the ease and 
readiness with which it can be performed, it is our best resource in those 




Fig. 389. — Porro operation. Uterus amputated above elastic ligature, which is placed on the 

lower segment. 

cases of severe and uncontrollable hemorrhage that sometimes occur in the 
course of the Csesarean section. 

Technic. — As in the case of supravaginal hysterectomy, the patient 
should be in the Trendelenburg position, and the uterine incision should 
be at the fundus in order to prevent, as far as possible, the escape of the 
uterine contents into the abdominal cavity. As soon as the foetus and 
placenta have been delivered, strong traction should be made upon the 
uterus by an assistant, and the operator should convince himself that the 
bladder is not drawn up also. Should this be the case, the bladder should 
be pushed down and out of the way by the finger wrapped in gauze. The 
rubber constrictor should then be applied as far down as possible and 
the uterus with tubes and ovaries is amputated an inch above the con- 
strictor. A sterilized knitting needle or some similar instrument passed 
through the stump and resting on the surface of the abdomen prevents 



THE CESAREAN SECTION 649 

it from falling back. The abdominal incision is then closed, except where 
the stump protrtides, and here the peritoneum is carefully sewed to the 
peritoneum of the stump, below the rubber constrictor. 

The stump should then be cauterized, dusted with an antiseptic powder, 
and covered with sterile gauze. 

Separation of the stump occurs in about two weeks, but three weeks 
more may be required before cicatrization is complete. 

Sterilization of the Patient. — Some writers have advocated the steril- 
ization of the patient with the view of preventing the necessity for 
subsequent Csesarean sections. There was undoubtedly more justification 
for this procedure in former years when the mortality of the operation was 
almost prohibitive. At present it hardly seems to be called for, except in 
cases of osteomalacia. 

If sterilization is decided upon, the best procedure is supravaginal 
hysterectomy, already described. Other methods are uncertain or danger- 
ous. Ligation of the tubes has been shown to be ineffectual, and removal 
of the ovaries is dangerous at this time, since the descending uterus, by 
dragging upon the pedicles, may cause slipping of the ligatures. The 
fundal incision, extended so as to permit the excision of the proximal ends 
of the tubes, is effective, but in this case the incision is a long one and, 
should any infection be present, the danger of its transmission to the 
peritoneal cavity would be considerable. 

Repeated Cesarean Sections in the Same Patient 
One Csesarean section is no bar to another. Women who have had two 
operations of this kind are not infrequently seen in the maternity hospitals 
of New York. One of my own patients had three, and other observers 
have reported cases in which the number was four or even five. There 
is undoubtedly a slight risk of uterine rupture in subsequent labors. The 
danger is slight, however. Broadhead, in his review, found but twenty 
cases in the entire literature of the subject. Probably in most of these 
cases the old incision in the lower uterine segment had been employed. 
Of course a patient who has been subjected to the operation should not 
be allowed to linger long in labor. 

Extraperitoneal (Suprasymphyseal) Cesarean Section 
(Figs. 390 and 391) 

Seeking to obviate the dangers of the classical Csesarean section in 
cases of possible infection, and also to do away with intestinal and epiploic 
adhesions, Frank has recently devised a method of gaining access to the 
foetus through the lower uterine segment, after stripping the latter of its 
peritoneum. 

Technic. — A transverse incision is made about two fingers' breadth 
above the symphysis, the recti are separated, and the bladder and anterior 
surface of the lower uterine segment brought into view. With the finger. 



650 



OBSTETRIC SURGERY 



wrapped in gauze, the bladder is pushed to one side and the peritoneal redu- 
plication of the lower uterine segment pushed well upward. In the 
anterior wall of the segment thus exposed, a longitudinal incision is made. 
The segment is distended by the presenting part and its walls are very 
thin, so that caution is necessary to avoid injuring the child while making 



ADMERENTPERITONtUr^ 



HEA^RT SOUNDS 



+ 







RDUN& UGAHEHT 



CULDESAC PERITONEUM 




BOUND LIGAMENT 

UTERInE VEIM 
LOWER SEGHENT 



BLADPER 



Fig. 390. — Extraperitoneal Ccesarean section, showing anatomical relations of peritoneal cul de sac, 

bladder and left side of uterus. 

the incision. The foetus is then delivered, either by simple pressure or 
by forceps or version, according to indications. 

After the delivery of the placenta and membranes, the uterine wound 
is closed with a running catgut suture, and the abdominal wound closed 
in three layers, recti, fascia and skin. 

The exposure and incision of the lower uterine segment do not present 



THE CESAREAN SECTION 



651 



great technical difficulties, but the incision is not infrequently too small 
for deliver}- without laceration. As a matter of fact, the peritoneum 
has been torn in many cases. Infection of the cellular tissue, sometimes 
of severe type, has also been noted. 

Doderlein has recently practised a modification of this operation, in 



PtRlTOMEUM 




-ROUND U6AHENT 



^ UTERIHE VEIN 



URETER 



BtAPPaR 



Fig. 391. — Extraperitoneal Caesarean section. Incision of lower segment after pushing back the 

peritoneal cut de sac. 

which the incision instead of being median, i.e., above the symphysis, is 
lateral and parallel toi Poupart's ligament, the lower uterine segment being 
entered from the side. This is practically a revival of the laparo- 
elytrotomy of Gaillard Thomas, tested and abandoned here in the early 
seventies. These operations were devised and advocated with the idea 
that they would prove safer, in cases possibly infected, than the classical 



652 OBSTETRIC SURGERY 

Csesarean section. It has been shown, however, that even if there is no 
injury to the peritoneum, severe infection of the cellular tissue may occur. 
Moreover, they are technically much more difficult than the Csesarean sec- 
tion. The peritoneum has been torn many times and even if there is no 
injury to the peritoneum, severe infection of the cellular tissue may occur. 
In one of Doderlein's cases hemorrhage was so severe that he was com- 
pelled to desist and resort to the consen^ative operation. Thus far these 
operations have gained no favor in America. 

Post-mortem Cesarean Section 

If a woman dies during pregnancy and there is reason to believe that 
the foetus is viable, an immediate Caesarean section should be performed. 
It is quite true that a living child will seldom be secured, but the physician 
will have done his duty in the matter and he may be quite sure that the 
mother, if able to, would commend his course. The whole procedure need 
occupy but a moment, as no preparation is necessary. The incision should 
be promptly and carefully repaired. Xo time should be lost. It is folly 
to waste time listening for the fetal heart. Performed in this manner, 
the Caesarean section is less revolting than the accoiicJicinoif force and 
gives a much better chance of securing a li^^ng child, since if the pelvis is 
small or the head large the child is inevitably lost. The consent of those 
nearest the patient should, of course, first be obtained, if possible, though 
the law does not require this. 

Puech, quoted by Garrigues, found that in 331 operations loi children 
showed signs of life when born, but only 43 survived. Cases have been 
reported in which the child lived twenty minutes, or even more, after the 
death of the mother. ]\Iost of these cases are apocr\^phal. AA'hen the 
mother dies suddenly, as from the result of an accident, the foetus is more 
likely to survive her death for a few moments than if she dies as the 
result of some exhausting disease. 



CHAPTER XXX 
SYMPHYSIOTOMY AND PUBIOTOMY 

The idea of securing the delivery of a living child by dividing the 
bony girdle of the pelvis has long occupied the minds of those interested 
in obstetrics. It has been carried into effect in two ways : by dividing the 
pubic joint (s}Tiiphysiotomy), and by dividing the pubic bone at one side 
of the joint (pubiotomy). Let us first consider the older operation. 

Symphysiotomy 

Historical Note. — The operation was first performed by Sigault, of 
Paris, in 1777, but soon fell into disuse. Morisani, of Naples, revived the 
operation in 1866, and since then it has been generally practised in Italy, 
although of late it has been in large measure displaced by the newer 
operation of pubiotomy. In 1892, Pinard's advocacy of symphysiotomy 
rendered it popular in Paris, and it was first performed in this country 
by Garrigues on December 30th of the same year. 

Technic. — Careful asepsis, including shaving of the mons veneris and 
lower abdomen. As these cases are practically all emergency cases, it is 
perhaps better simply to cut the hair close about the pubes and paint the 




\ Mlg 



Fig. 392. — Galbiati's falcetta. 

parts with tincture of iodine. The patient should be placed in the dorsal 
position, with the bladder and rectum empty, and the thighs flexed and 
rotated outwards, in order to open and make more accessible the pubic 
joint. 

But few instruments are required : a scalpel, a thumb-forceps, a few 
clamps, a needleholder and needles, as for any minor cutting operation ; 
also, and these are indispensable, a metallic catheter or sound for holding 
the urethra to one side, and a stout blunt-pointed bistoury, or the sickle- 
shaped knife of Galbiati, for dividing the symphysis. The obstetric for- 
ceps should be at hand, as well as everything necessary for resuscitating 
the child (Fig. 392). 

Two medical assistants are desirable, one to give the aucxsthetic and 
another to assist directly at the wound, and to resuscitate the child if 
necessary. Two more assistants whose duty it is to make pressure in the 

653 



654 



OBSTETRIC SURGERY 



region of the trochanters and prevent undue separation at the symphysis 
are absolutely necessary. The latter need not necessarily be physicians, 
but should be carefully instructed in advance, as the duties which they have 
to perform, and which will presently be described, are important. 

An incision, 5 or 6 centimetres in length, is made, exactly in the median 
line, and extending from a finger's breadth above the symphysis to just 




Fig. 393. — Veins of the prevesical space. Front view of the bladder and dorsal surface of the 
clitoris, the right crus of which, as well as the right side of the pelvis, has been cut away. P, internal 
pudic vein, receiving blood from the dorsal and cavernous veins of the clitoris, the urethral and anterior 
vesical veins, as well as from below from the bulb, the perineum, and the anus, which have been cut 
short; V, large vesical trunk, receiving blood from the vesical plexus, which anastomoses with the 
tributaries of the internal pudic vein. A pin has been placed between the two chief veins. 



above the clitoris. This incision divides the insertion of the recti muscles, 
but avoids the transversalis fascia beneath. The finger, passed down the 
front of the symphysis, feels the sharp edge of the ligamentiim arcuatum, 
the suspensory ligament of the clitoris is divided by a transverse incision, 
and the clitoris itself drawn down and out of the way. The finger is then 
passed behind the symphysis into the prevesical space, and the tissues 



SYMPHYSIOTOMY AND PUBIOTOMY 655 

carefully separated from the posterior surface of the symphysis, and for 
a distance of 2 or 3 centimetres on each side, in order to prevent injury 
to the bladder during the division of the joint. A sound is now passed 
into the bladder, and an assistant holds it well to one side, thus protecting 
the urethra and bladder from injury, wdiile the operator divides the 
symphysis and the subpubic ligament, from above downward and from 
before backward. 

After the division of the symphysis the bones separate of themselves, 
but a too sudden, or great, separation should be prevented by the assistants. 
The amount which may occur without apparent harm is sometimes remark- 
able, but a separation of more than 6 or 7 centimetres should not be 
permitted, as it endangers the integrity of the sacro-iliac joints. 

Hemorrhage. — Considerable bleeding may occur at this time from the 
veins of the prevesical space. The accompanying illustration from 
Garrigues well shows the abundant venous supply of this region. This 
hemorrhage may usually be checked by firm and continued pressure. As 
a rule suturing does more harm than good. The needle pricks bleed freely 
and it is impossible to suture the w^hole mass (Fig. 393). 

Delivery After the Division of the Symphysis. — The symphysiotomy 
proper is now complete. If this were all, patient and physician would 
indeed be fortunate, but the child is still to be delivered, and this delivery, 
especially if the child be large, or if we have overestimated the size of the 
pelvis, is by far the most formidable part of the operation. The soft 
parts behind the symphysis have lost their natural support, and may be 
extensively torn during extraction. These tears may involve the bladder 
or urethra, or large veins in the lowxr part of the prevesical space may be 
involved, severe hemorrhage resulting. 

After the division of the symphysis and during the delivery which is 
to follow, the assistants, one on each side, keep up pressure in the region 
of the trochanters, and must be constantly on their guard against too great 
a separation (Fig. 394). 

In Italy, where the operation has been long and extensively practised, 
it is customary to leave the patient for two hours or so in labor ; immediate 
operative delivery being practised only when specially indicated, or when 
the head has descended to the floor of the pelvis. This is also the custom 
of Zweifel, a very successful operator in this field. In my 'opinion, it is 
the best method. I am convinced that many of the bad results in symphysi- 
otomy have been due to hasty and unskilful deliveries, especially versions. 
If operative delivery becomes necessary, the forceps should be preferred 
as far safer for the child ; and this applies to pubiotomy as well. It is 
irrational to subject the mother to an operation like symphysiotomy or 
pubiotomy for the express purpose of saving the life of the child, and 
then to select, as a method of delivery, that which is most dangerous to 
the child. I have seen some very difficult versions after symphysiotomy. 

It is highly important that a good forceps operator be in attendance. 



656 OBSTETRIC SURGERY 

The axis-traction forceps are preferable, as imposing less strain upon the 
soft tissues behind the symphysis and making less pressure upon the fetal 
head. During the final extraction of the head it should be held well back, 
against the sacrum, and when the head is brought over the perineum the 
handles should not be raised as much as usual, since it is justifiable under 
these circumstances to incur a somewhat greater risk of perineal laceration 
than at other times. 

After the delivery has been completed, the thighs are extended and 
rotated inward in order to close the joint, care being taken that the bladder, 
or other soft structure, is not caught between the ends of the bones. 

The tissues in front of the symphysis are united by sutures of silkworm 



i J ■ 



v\ 




\ 



Fig. 394. — Separation, with injury to soft parts, prevented by pressure over trochanters. 

gut. Experience has shown that it is not necessary to suture the bone or, 
cartilage, and such sutures may suppurate. A gauze drain is left in the 
upper end of the wound, and there should be separate dressings for the 
vulva and vagina. This to avoid, if possible, the contamination of the 
wound by the lochial secretion. 

After-treatment. — No complicated apparatus is necessary. Broad 
strips of rubber adhesive plaster, drawn tightly about the pelvis, suffice 
to keep the ends of the symphysis in apposition, and have the advantage 
of being waterproof (Garrigues). The Bradford frame or the hammock 
bed of Ayers are convenient and conduce to the comfort of the patient. 
A retention catheter is advisable for the first week or two, in order to 
avoid the joint movement attendant upon too frequent catheterization. 
The patient should remain in bed for three weeks. 

Other Methods. — Morisani divides the symphysis from behind for- 
ward, and from below upward, by means of the falcetta or sickle-shaped 
knife of Galbiati. Zweifel uses a Gigli saw, and saws through the sym- 



I 



SY^IPHYSIOTOMY AXD PUBIOTOMY 657 

phvsis as one divides the pubic bone in pubiotomy. Harris modified the 
operation by Hmiting the incision to the joint proper and not dividing the 
subpubic Hgament. He separates the latter, however, for a distance of 
2 or 3 centimetres on either side, seeking thus to avoid tears of the venous 
plexus. 

In the subcutaneous method of Ayers, the clitoris is drawn down and 
an incision made just above it. A blunt-pointed bistoury is then introduced 
into the opening and carried to the upper border of the symphysis, where 
it is met by the index finger in the vagina. Finger and bistoury are then 
brought down together until they approach the subpubic ligament, when, 
in order to avoid hemorrhage, the bistoury is removed and reentered with 
its cutting edge upward. 

Pubiotomy 

Gigli, in 1893, revived the old idea of dividing the pubic bone at one 
side of the symphysis instead of dividing the symphysis itself. 

The operation has been taken up with enthusiasm in many quarters 
and. for the present at least, has almost driven the rival operation of 
symphysiotomy from the field. There are still some well-known operators, 
however, who cling to the latter operation, among them being Pinard, 
Zweifel, and Kerr. 

Technic. — The operation was first performed by the open method ; 
i.e., the entire width of the bone was exposed, the saw being used under 
the guidance of the eye. This method deprives the severed bone and also 
the important soft structures posterior to the bone of all support. 

Doderlein modified the operation by making the incision above the bone 
and completing the operation subcutaneously. 

Bumm's method is entirely subcutaneous. No scalpel is used, the 
needle being entered just above the upper border of the bone and made 
to emerge just below the lower border. 

Of these operations, that of Doderlein is probably the safest. It leaves 
to the severed bone and underlying tissues the support of the soft parts 
and at the same time permits the introduction of the finger to separate the 
tissues and guide the needle (Fig. 395). 

The preparations are much the same as for symphysiotomy, but to the 
instruments already mentioned must be added two or three of the chain 
saws of Gigli. More than one of these are needed, since the instrument 
sometimes breaks, and without another the operator would be obliged to 
abandon the operation. The porte scie, or saw carrier, a long heavy 
needle with an eye In the point, is also required, though in an emergency 
its place may be taken by a long curved artery forceps. 

An abundant supply of gauze for tampons should be at hand ; also two 
or three pairs of rubber gloves, since the operator must change his gloves 
during the operation. 

The patient is placed in the dorsal position with the legs flexed and 
42 



658 



OBSTETRIC SURGERY 



rotated outward. After making sure that the bladder is empty, the oper- 
ator first carefully locates the symphysis and then the pubic spine. A 
transverse incision just above the pubic bone, extending inward from the 
pubic spine and large enough to admit the finger, is made. This incision 
is ordinarily on the left side, since, unless the operator is left-handed, he 
can work better on this side. It goes down to and through the fascia of 
the rectus muscle and no farther, since this is sufficient to give access to the 
posterior surface of the bone. 

The left index finger is now introduced into the wound and the tissues 



Pubic bone 




Uterine wall 



Bladder 



Bladder 



Fig. 395. — Pubiotomy, Doderlein's method. 

separated from the posterior surface of the bone. The operator now takes 
in his right hand the needle of Doderlein and passes it along the posterior 
surface of the bone until it emerges at its inferior border. During its 
entire course the needle is kept close to the bone and its movements are 
guided and controlled by the finger of the left hand in the vagina. 

The finger which has been introduced into the vagina should on no 
account be allowed to contaminate the pubiotomy wound. The operator, 
therefore, changes his gloves before proceeding further with the operation. 
One end of the saw is now attached to the lower end of the needle and 



SY^IPHYSIOTOMY AND PUBIOTOMY 



659 



the latter is drawn upward until the saw appears in the upper incision. 
The handles are then attached and a few oscillations suffice to sever the 
bone. The saw should never be bent at an acute angle, but held as in 
Fig. 397. 

Hemorrhage may be quite free, from both ends of the wound, but as in 
symphysiotomy is best controlled by compression. This compression 
should'be continued for a day or two to prevent the formation of haemato- 
mata, which are very likely to develop after this operation. A firm tampon 
in the vagina serves the same purpose. 

When the sawing through of the pubis is almost complete, the thighs 



T '^ 




Fig. 396. — Pubiotomy, open method; passing the saw-carrier. 

should be adducted and pressure made on each side by the assistants, who 
should be cautioned not to permit a too sudden or too great separation. It 
is not usually wise to permit a separation of more than 3 centimetres. 

Delivery of the Foetus. — What has been said of delivery after sym- 
physiotomy applies here. If the head does not at once descend, it is far 
better to wait for an hour or two than to risk the severe lacerations that 
may be the result of operative delivery under these circumstances. Bumm, 
with a large experience in this field, emphasizes this point strongly. Aver- 
sion should be avoided as dangerous to the child as well as the mother, 
and likely to defeat the very object for which the operation is performed. 
If the use of the forceps becomes necessary, the same precautions are to 



660 



OBSTETRIC SURGERY 



be observed as in the case of symphysiotomy. If dehvery is to be delayed, 
the vagina should be tamponed, compresses applied to the cutaneous 
wounds, and the pelvis encircled by a firm bandage. 




Fig. 397. 

After-treatment.— 



-Pubiotomy, open method; the chain saw in use. 



It is better not to use the catheter unless absolutely 

\\'illiams followed this 
plan in his cases and with good results. A wide strip of adhesive plaster, 
or the bandage of Garrigues, serves to immobilize the pelvis. The patient 



necessary. The danger of cystitis is too great. 



SY^IPHYSIOTOMY AND PUBIOTOMY 661 

is allowed to lie upon her side after the first day and to leave the bed in 
about two and one-half weeks (Fig. 398). 

Indications. — The indications for these operations may be considered 
together. It is generally stated by those who advocate their use that they 
are indicated in flat pelvis, when the true conjugate is from 7 to 9 centi- 
metres. Aly own experience leads me to believe that if the conjugate does 
not exceed 7 centimetres the Caesarean section is preferable. The size of the 
head is such an uncertain factor that it is not well to approach the lower 
limit^ too closely. After all, it is not a matter of centimetres, but of the 
relation of the head to the pelvis, as shown by the test of labor. The 
thinking man does not reason in terms of centimetres, but takes into his 
estimate all the factors in the individual case. 

Therefore, I do not advise either of these operations as an elective 
procedure. In other words, I would not choose one of them in advance, 
simply because the patient has a moderate contraction of the pelvis' 
Abundant experience 
has shown that in these 
border-line cases no one 
can determine the result 
in advance. How many 
times has an expected 
symphysiotomy termi- ' 
nated in a precipitate 
labor ? ' 

Viewed in proper 
perspective, a long list 
of pubiotomies per- 
formed by a good ob- 
stetric surgeon with a small maternal mortality, or perhaps none at all, 
proves simply this : that in competent hands and in selected cases such an 
operation is not necessarily fatal. When all is over, however, no one, not 
even the operator himself, knows how many operations were indicated. 

Some enthusiasts have gone so far as to advise pubiotomy as a substi- 
tute for the forceps operation or version in these border-line cases. Those 
who recall the rapid rise, and still more rapid fall, of symphysiotomy must 
regard this view with skepticism. Then, too, it is highly significant that 
those who have had much experience with the operation advise that it be 
performed only by experienced operators. It is true that in the doubtful 
cases version is very often fatal to the child, but if the head can be made 
to engage, careful and tentative use of the axis-traction forceps can do 
no great harm, and gives the mother the benefit of the doubt. If the case 
is not infected, and if it is plain that pelvic contraction is the cause of delay, 
the Csesarean section is far safer for the child, and equally safe for the 
mother. It is true that certain over-zealous advocates of pubiotomy will 
rejoin that the operation can only be judged fairly when it is performed 




Fig. 398. — Garrigues's symphysiotomy bandage. 



662 OBSTETRIC SURGERY 

as an elective procedure. To this the obvious reply is that our obligations 
are to the patient and not to the operation. 

A palpable disadvantage of both operations is the fact that the fate of 
the child is always doubtful. Even though the section of the symphysis or 
the division of the pubic bone has been skilfully performed, the subsequent 
delivery may prove unexpectedly difficult. The size of the head is always 
an uncertain factor. I have heard of one case in which, even after the 
division of the symphysis, the head could not be extracted until it had 
been perforated. This occurred at the hands of an exceptionally skilful 
operator. 

At the last analysis, then, these operations are operations of necessity, 
not of choice. If circumstances permit us to determine our course in 
advance, it is better to perform the Csesarean section and be fairly certain 
of a living child. 

There is, however, a certain class of cases, very limited in number, it 
is true, but definite, in which the indication for opening the pelvis is clear. 
If the head is wedged in the pelvis, so that a little loosening of the pelvic 
diameters is all that is necessary, -if the child is living and viable, if the 
condition of the mother, as to asepsis and resisting power, contra-indicates 
the C?esarean section, and if a careful trial of the forceps by a good 
operator has failed, it would seem that pubiotomy or symphysiotomy is 
indicated. Such cases are rare indeed. They are most commonly the result 
of an overlooked outlet contraction, or of a face or brow presentation, 
or a persistent occiput posterior. To undertake either of these operations 
simply because the pelvic diameters fall within certain limits, or because 
the head remains above the brim of the pelvis, seems to me to pass the 
limit of justifiable experimentation. 

It goes without saying that the child must be living and viable, and 
that the cause of delay must be pelvic contraction, and not some other 
and remediable condition. The one exception to this is to be found in 
cases in which the cause is a large head, or the presentation of one of the 
greater diameters, as in face or brow presentation. In these cases, of 
course, the pelvis is relatively if not actually small and the indication is 
really of the same character. 

Which of these operations shall be chosen ? Symphysiotomy opens the 
pelvic girdle more promptly and widely. This is certainly an advantage, 
but in the class of cases of which I have spoken the extra space allowed 
by pubiotomy, about 3 or 4 centimetres, is ordinarily sufficient. 

It is claimed that in pubiotomy there is less danger of lacerating the 
adjacent soft parts, bladder, urethra and anterior vaginal wall. This is 
doubtful. Pubiotomy, however, has one undeniably great advantage. 
The bony wound usually heals promptly like a simple fracture, and thus 
there is less likelihood of subsequent disability, the after-treatment is less 
tedious and troublesome, and convalescence is much less prolonged. 

If we must choose between the two operations, the latter considerations 



SY^IPHYSIOTO^IY AND PUBIOTOMY 663 

settle the question in favor of pubiotomy. In my opinion the necessity for 
the choice will seldom arise. 

Prognosis of the Two Operations. — With reference to prognosis, 
statistics are very confusing and unsatisfactory. It was at first claimed 
that pubiotomy is much safer than symphysiotomy, but this conclusion, 
"which is a priori improbable, has been shown to be incorrect. 

The combined statistics of Maier (1907) and Schlafli (1909) give an 
average mortality of 5.21 per cent. This refers, however, to the early days 
of the operation, before its technic was perfected. Later statistics from 
the German clinics, and from Johns Hopkins Hospital, indicate that the 
mortality in good hands should not exceed 2 per cent., and Williams is 
probably correct in saying that the mortality is about the same as that of 
the elective C?esarean section. The fetal mortality is, of course, much 
higher. 

An analysis of recent statistics goes to show that the mortality of 
symphysiotomy is about the same, though convalescence is much more 
prolonged. 

But the above mortality presupposes that the patient is uninfected and 
all the conditions favorable, and the question naturally arises, " Why, under 
such conditions, perform these operations at all? " 

AVho Shall Perform the Operation? 

We are accustomed to hear the statement that only an experienced 
surgeon should perform these operations. I would reverse the proposition 
and say that only an obstetrician should have the case in charge. First, 
and most important, he alone will be able to determine whether the 
operation is indicated. Moreover, the difficult and critical part of the 
operation is not the division of the symphysis or the pubic bone, but the 
subsequent delivery of the foetus. This should certainly be in charge 
of an expert obstetrical operator, if such can be procured. It is during 
this period that the danger to both mother and foetus is greatest ; to the 
foetus from asphyxia, and to the mother from extensive lacerations of the 
unsupported structures behind the svmphysis. 

I cannot too strongly emphasize this point, which I have had abundant 
opportunity to confirm from personal observation. 



CHAPTER XXXI 
EMBRYOTOMY 

By the term embryotomy is meant the mutilation of the foetus for the 
purpose of effecting a dehvery which would otherwise be difficult or 
impossible. The term is a generic one, and includes various subdefinitions, 
e.g., craniotomy, perforation, decapitation, evisceration, cleidotomy (divi- 
sion of the clavicle), etc., terms that for the most part explain themselves. 
The term craniotomy, which means the perforation or crushing of the 
fetal cranimn, is often used as a synonym for embryotomy. This use 
of the term is objectionable, not only because it is bad English, but because 
it leads to confusion in the mind of the student. 

Indications. — At the outset we are met by the question, ''Are we 
justified in performing embryotomy upon the living foetus under any 
circumstances ? " This is an ethical, rather than a scientific, question, and 
one upon which I do not propose to enter. Here, as elsewhere, the phy- 
sician must be guided by the dictates of conscience. The majority of 
physicians believe that there are occasional instances in which the sacrifice 
of the child is the only method of saving the life of the mother, and that 
in such cases it is justifiable. 

The necessity for such a choice shouM never arise in a hospital, except 
perhaps in the case of a patient exhausted or infected when admitted. 
The Caesarean section has now become so safe that the deliberate and 
premeditated destruction of a living child seems altogether unjustifiable. 

In remote locaHties, however, where the attendant is without the 
assistance and appliances for an aseptic and reasonably skilful operation, 
he may be obliged to sacrifice the child or lose both patients. This pain- 
ful necessity may occasionally arise as the result of pelvic contraction, 
of hydrocephalus, of brow presentation, or of face presentation with the 
chin posterior. 

If the head is impacted in the pelvis, and the attendant has some surgical 
skill, he may venture a pubiotomy. 

These emergencies would seldom occur if patients were taught that 
they should not wait until labor begins before consulting a physician, and 
if all physicians realized the importance of perfecting themselves in ante- 
partum diagnosis, and of examining their patients before the beginning 
of labor. 

Repeated embryotomies upon the same patient usually indicate a poor 
obstetric equipment as well as a criminal disregard for human Hfe. 

Physicians living in country districts should combine to establish 
emergency hospitals in which cases of this kind could be treated. In every 
group of a half dozen physicians there is at least one who has a special 
664 



E^IBRYOTO^IY 665 

aptitude for surgery. Some great achievements in surgery have been 
performed in just such emergency hospitals in our own country, and I 
believe that the plan here outlined would diminish, or almost abolish, the 
necessity for embryotomy upon the living child. 

Whatever one may think about craniotomy upon the living foetus, there 
can be no doubt that craniotomy upon the dead foetus should be performed 
much oftener than it is. AMiat are the indications for embryotomy upon 
the dead foetus? 

In a general way, it may be said that whenever the foetus is dead and 
an operation of even moderate difficulty seems required for its delivery, 
embryotomy should be practised. But we must be sure that the child is 
dead. How are we to ascertain this? Absence of the fetal heart-sounds, 
of course, is not sufficient evidence of the death of the child. If, however, 
they have been heard shortly before their absence it is highly significant. 
The only positive evidence is prolonged absence of pulsation in the umbilical 
cord. Hence the following cardinal rule : Before any severe operation is 
performed for the purpose of effecting delivery, we should avail ourselves 
of every opportunity to determine whether the foetus is living, including, 
if possible, palpation of the cord, which can usually be practised when the 
head is movable above the brim and certainly in all versions. 

Nothing can be more stupid and cruel than to subject the mother to 
severe laceration, with possible subsequent disability and perhaps fatal 
infection, in order to avoid the necessity of perforating a dead foetus, and 
yet it cannot be doubted that this has many times been done. 

Perhaps the most typical instance is found in those cases in which 
frantic and unavailing efforts are made to deliver the after-coming head 
long after the child is dead and the cord has become cold and pulseless. 

I was once called in haste to deliver a patient because of prolapse of the 
cord. The head presented. There was no doubt of the diagnosis, but 
noticing the small size of the abdomen, I inquired the date of the last 
menstruation, and learned that the patient was only six and one-half 
months pregnant. Obviously there was no need of operative interference. 

Centra-indications. — If the true conjugate measures less than five and 
one-half centimetres, the operation is impossible. If less than seven centi- 
metres, it is at least as dangerous as the Csesarean section. Cervical dila- 
tation is, of course, necessary, and if the cervix is not completely dilated, 
dilatation should be completed manually or otherwise, 

Technic. — Craniotomy, the most common form, will be first consid- 
ered. It is divided into two stages : first, perforation and evacuation of the 
skull; second, extraction. 

First Stage. — Bladder and rectum should be empty. All available 
room is needed. Asepsis should be rigorous, since these cases seem pecu- 
liarly likely to be followed by infection. Such an operation should never 
be performed in bed. The patient should be in the lithotomy position with 
the hips drawn well over the edge of the table. It is hardly necessary to 



666 



OBSTETRIC SURGERY 



say that the membranes should be ruptured and the cervix dilated. Anaes- 
thesia is not always necessary, but if it is not used the nature of the 
operation should be carefully concealed from the mother. If it is used, 
ether is usually to be preferred in these neglected and exhausted cases. 
Instruments necessary are the perforator of Blot or Simpson, the cranio- 




FiG. 399. — Simpson's perforator. 

clast of Braun, and in difficult cases the basiotribe of Tarnier. The per- 
forator of Blot is much to be preferred to that of Simpson, especially in 
difficult cases, since it cannot injure maternal tissues or the fingers of the 
operator. He who possesses a basiotribe needs neither perforator nor 
cranioclast, since both are contained in this instrument. 

When all is ready, a final examination is made to determine the exact 
condition of affairs and make sure that the operation is really necessary. 



X 



\ 





Fig. 400. — Perforation. An assistant holds the head firmly in position. His task is an important one. 



An assistant then firmly presses the head down (Fig. 400) into the 
brim of the pelvis and holds it there. The point of the perforator is 
kept as nearly as possible at right angles with the skull and is made to 
penetrate the skull by a '* boring " movement. But little force is required. 
If the Simpson instrument is used, great care must be taken not to^ injure 
the maternal soft parts. In an emergency any long, straight scissors may 



EMBRYOTOMY 



667 



be made to sene every purpose. AVhatever instrument is used it should 
be held lightly, but firmly, against the skull and the guiding fingers of the 
left hand should not leave their position imtil the instrument has become 
buried within the cranium. The blades are then separated and moved about 
in all directions, thus breaking up the brain substance and facilitating its 




Fig. 401.— Cranioclast of Braun and method of using. 

evacuation. This process should be especially vigorous in the neighbor- 
hood of the medulla and base of the brain, in order to avoid the possibility 
of the birth of a living but mutilated child. 

It is better to perforate a bone than a fontanelle, since the latter may 
close again. In vertex presentations the puncture should, if practicable, 
be made near the occiput. This promotes flexion when traction is made 



668 



OBSTETRIC SURGERY 



with the cranioclast, and thus the mechanism of labor is more closely 
imitated. After perforation the scalp should be so arranged as to cover 
ragged edges of bone. It is a waste of time to wash out the cavity of the 
skull, since the cranial contents exude freely as compression is made. 



/■"k 




Fig. 402. — Application of the cranioclast in brow presentation. An assistant holds the right blade 
well back and to one side, while the operator applies the other blade over the face. 

Extraction. — The head having been perforated and the cranial con- 
tents evacuated, there still remains the task of extraction. In some cases 
this is easy and may be accomplished by the ordinary obstetric forceps. 
In others it is unexpectedly difficult and may tax the resources of an 
experienced operator. 



EMBRYOTOMY 



669 



For this purpose many instruments have been devised. Two only have 
stood the test of time. These are the cephalotribe and the cranioclast. 
The cephalotribe is in substance a massive and powerful pair of forceps, 
designed for both crushing and extracting. The heavy blades, however, 
take up considerable space, and when the head is compressed in one of its 
diameters it is often proportionately elongated in another. It is now 



~;|^ 



X/ 




Fig. 403. — Cranioclast applied and handles screwed together. 

seldom used, except in cases in which it becomes necessary to crush the 
base of the skull, and even here the basiotribe, to be described presently, 
is much more effective. 

A more practical and useful instrument is the cranioclast of Braun 
(Fig. 401), whose construction and appearance are here sufficiently illus- 
trated. Since one of its blades is passed within the cavity of the skull 



670 OBSTETRIC SURGERY 

and the other is buried in the tissues of the scalp or face, it takes up prac- 
tically no room and adds nothing to the bulk of the head. Furthermore,, 
it is easier of application, and its application is attended with less maternal 
traumatism. As suggested by Munde the cranioclast is really a cranio- 
tractor, and should have been so named. True, it may be and sometimes 
is used to comminute the cranial vault, but this use is incidental or acces- 
sory, its chief function being to make traction upon the fetal head. Under 
the influence of this traction, the head, having been emptied of its contents, 
becomes elongated and moulded to the shape of the pelvic canal, as shown 
in Figs. 40? and 403. 

Cranioclasis 

The extraction of the head by means of the cranioclast Is known as 
cranioclasis. The inner or non-f enestrated blade is first introduced. This 
is carried under the guidance of the fingers through the perforation already 
made in the skull and held in position by an assistant. The location of the 
perforation should vary with the position of the head. In occiput positions 
it should be near the occiput so as to favor flexion. . In face presentation 
it should be at the root of the nose, in order that when traction is made 
extension of the head and descent of the chin may occur. To recount 
every possible contingency would carry us too far. The following illus- 
trations will serve to refresh the memory and make plain the principle 
involved. 

Though intended primarily for traction the cranioclast isi often used 
for comminuting the bones of the cranial vanity, thus reducing its size 
and rendering its passage easier. The instrument remains in situ during^ 
the process and is moved about from one place to another, comminuting- 
successive portions of the scalp as they can be reached. No attempt is 
made to remove the pieces of bone. These are left covered by the scalp, 
and the fact that they are so covered should be determined by examination. 

Traction is made as far as possible in the axis of the pelvis. A steady 
pull, longer than in the forceps operation, is allowable, and indeed advisable. 
Thus is the head elongated and moulded. The operator should guard 
against slipping, and the force employed should be moderate. 

Extraction with the cranioclast is not always easy, even when evidence 
of pelvic contraction is absent. The head may be very large or may 
present unfavorably, or there may be undetermined factors of difficulty. 
For example, when the head is impacted in the pelvic brim it is not always 
easy to determine with what kind of pelvis one has to deal. 

In these cases the inexperienced operator sometimes redoubles his 
efforts. It is unwise to persist in unavailing efforts which can only result 
in increased shock. It is better to resort to version. The head, now dimin- 
ished in size, presents no great obstacle to the seizure of a foot or knee, and 
if the uterus is not tetanically contracted the after-coming head is easily 
extracted. 



EMBRYOTOMY 671 

If, owing to the scanty pelvic space, difficulty is encountered in reaching 
a foot or knee, the patient should be turned upon her side. I recall a case 
in which this manoeuvre was successful after all previous attempts at 
delivery had failed and was, I believe, the means of saving the Hfe of the 
patient. 

Cephalotripsy 

The process of crushing the head, or some part of it, by means of the 
cephalotribe, is known as cephalotripsy. As in the forceps operation, the 
head may be above or below the brim of the pelvis. In the former case we 
speak of high cephalotripsy, and in the latter of median or low cephalo- 
tripsy. Let us begin with the latter. 

Median and Lov^ Cephalotripsy. — Whenever possible, the blades are 
applied to the sides of the head, as in the forceps operation. They are then 
slowly and gradually approximated by means of the compression screw. 
Extraction should be slow and no effort made to drag the head through 




Fig. 404. — Tarnier's cephalotribe. 



the pelvis by brute force. Frequent examinations should be made to deter- 
mine the presence of projecting spiculse of bone. 

High Cephalotripsy. — Here, as in the forceps operation, and for the 
same reasons, no attempt should be made to apply the blades to the sides 
of the head, but the latter should be seized, if possible, by one of its oblique 
diameters. Extraction with the cephalotribe may prove difficult or impos- 
sible, and it is better, if difficulty is encountered, to substitute the cranio- 
clast or to perform version. If practicable, such a patient should be 
transported to a hospital where basiotripsy may be performed by an expert 
(Fig. 404). 

Basiotripsy 

With perforator and cranioclast one may evacuate the skull and even 
break up and remove the cranial vault. There remains, however, the base 
of the skull, and if the conjugate diameter of the pelvic brim be less 
than 5^ or 6 centimetres this can hardly pass. 



672 



OBSTETRIC SURGERY 



The base, then, must be reduced in size. For this purpose the best 
instrument is the basiotribe of Tarnier. The process of crushing and 
extracting the head by means of this instrument is known as basiotripsy. 

The basiotribe is a combined perforator and crusher of the skull. It 
consists of three parts, a perforator and two blades, which together 
constitute a powerful cephalotribe (Fig. 405). 

If the blades of the, cephalotribe could always be applied accurately 
to the sides of the head, the crushing of the base of the skull would be a 
simple matter. AMien, however, the head is above the brim, as it usually 
is in these difficult cases, an exact cephalic application is impracticable. 
The genius of Tarnier was not long in overcoming this difficulty. He 
gave the basiotribe a double lock. This enables the operator to make either 




mjj3»i) 



Fig. 405. — Tarnier's basiotribe. 




blade longer at will and thus to apply the instrument effectively, no matter 
what the position of the head (Fig. 406). 

Technic. — The perforation of the skull and the evacuation of its con- 
tents are accomplished as in an ordinary craniotomy. Perforation may be 
made with the central branch of the basiotribe, which is in itself a per- 
forator. This is carried to the base of the skull, and the handle brought 
as far back as the perineum will allow and entrusted to an assistant. 

The blades are introduced according to the rules already given for the 
forceps operation. If the occiput is to the left, the left blade is introduced 
first, and vice versa. As in the forceps operation, if the head is above 
the brim, the blades are applied obliquely. One blade will be over the 
mastoid region and the other over the opposite temple. After the first 



EMBRYOTOMY 



eiz 



#^ 




/ 




K 



'^'T^.. 




43 



674 



OBSTETRIC SURGERY 





E^IBRYOTOMY 



675 



blade has been passed it is locked to the perforator, and by compression 
with the small screw the occipital region is crushed (Fig. 408). The 




.a' 



L 



Fig. 410. — Basiotribe extraction. 

second blade is now introduced, the pivot being inserted into the slot 
nearest the handle. This causes the second blade to penetrate more deeply 
and to embrace the entire circumference of the head, face and chin. This 



676 



OBSTETRIC SURGERY 



deeper insertion of the second blade, which is the distinguishing feature 
of the Tarnier instrument, not only makes it possible to reach the chin 
and crush the base of the skull, but also serves to prevent slipping, which 
would otherwise be unavoidable. The remainder of the crushing process 
is now accomplished by means of the larger compression screw (Fig. 409). 
This description, necessarily somewhat technical, will be made, I think, 

perfectly clear by the accompanying 
illustrations (Figs. 406-410) from 
Jeannin, who advises that if extrac- 
tion prove difficult, which is rarelv 
the case, the first blade be withdrawn 
and the second be used articulated 
with the perforator as one would use 
the cranioclast of Braun. 

In face presentation the perfora- 
tion should be in the neighborhood of 
an orbit, while in presentation of the 
brow it should be in the region of the 
large fontanelle. The blades are 
applied as already described. 

In basiotripsy of the after-coming 
head it may be possible to apply the 
blades transversely, and in this case it 
is, of course, better to use the slot 
near the end, making both blades of 
the same length. 

Here an assistant, making traction 
upon the breech, pulls the trunk 
strongly downward and to one 
side, while the perforator is carried 
through the occipital bone near the posterolateral fontanelle. If great dis- 
proportion exists, one cannot always reach this fontanelle. In such cases 
the trunk may be carried upward over the mother's abdomen, and the head 
perforated through the roof of the mouth or through the foramen magnum. 
The latter is, in my experience, the easier. 




Fig 



411. — Aspect of fetal head extracted by 
means of the basiotribe. 



Decapitatiox 

This is called for in neglected cases of transverse position, when the 
membranes have ruptured early and uterine retraction renders version 
impracticable or dangerous. 

Technic. — The bladder and rectum having been emptied, the first 
step, as in all these procedures, is to fix the presenting part, which in this 
case is the shoulder, at the brim ; in these cases, however, not as in vertex 
presentations by pressure from above, but bv traction from below. We 



E^IBRYOTOMY 



677 



have an excellent traction handle in the arm. In many of these cases the 
hand has become prolapsed and is found in the vagina or protruding from 
the vulva. Even when this is not the case, it is usually easy to find it and 
to bring it down. 

\Miile strong traction is made upon the hand and arm by an assistant, 
the operator encircles the neck with his left hand, and taking in his right 
a pair of long, strong, blunt-pointed scissors, like those of Dubois, makes 
a small incision in the most accessible part of the neck. Into this the 
scissors are gradually introduced, dividing the soft structures of the neck 
until the operator recognizes the 
resistance of the cer^dcal verte- 
brae. The spinal column is sev- 
ered by successive " bites " of the 
scissors. Meanwhile the left hand 
guides and controls the move- 
ments of the instrument and 
makes sure that it remains cov- 
ered by the soft structures of the 
neck (Fig. 412). These struc- 
tures should not be severed until 
after the cervical column has been 
divided, and it is perhaps better in 
difficult cases to leave the column 
unsevered until the extraction of 
the trunk, when it Avill either tear 
without harm or become easy of 
access. 

Extraction of the body is most 
conveniently effected by traction 
upon the arms (Fig. 415). 

When the neck is difficult of 
access we may have recourse 
to the crotchet of Braun. This 
famous instrument may be used 
for two purposes : first, for bring-- -r,,^ , c- t r^ u ■ a ^ u ^ fn 

^ ^ , . ' ^ Fig. 412. — Scissors of Dubois and crotchet of Braun. 

ing the neck within reach of the 

scissors, and second, to sever the spinal column. 

By traction upon the arm, the neck is made as accessible as possible, 
and under the guidance of the left hand the crotchet is made to encircle 
the neck and its handle then entrusted to an assistant, who makes traction 
while the operator proceeds to use the scissors, as already described 
(Fig. 414). 

If the operator does not succeed with the scissors, it remains to dis- 
articulate the cervical vertebrae, which is accomplished in the following 
manner: Seizing the handle of the crotchet, he makes traction as strong 




678 



OBSTETRIC SURGERY 



as is deemed safe and then rotates the handle, first to one side and then 
to the other, the whole process being carefully controlled by the full hand 
introduced into the vagina and high as necessary. As considerable force 
is required, this manoeuvre should be reserved for those difficult cases in 
which one cannot succeed by the method already described (Fig. 413). 
Extraction of the Trunk. — This is best effected by traction on the 



_ y 




Fig. 413. — The use of Braun's hook. 

arm, and here little difficulty is usually experienced, though in rare cases 
version may prove the easier method. Extraction of the head, however, 
may prove a more difficult matter. 

The retention of the separated head iii utero is a complication occasion- 
ally encountered by the practitioner, not only in cases of the kind here 
considered, but in other cases. For example, the head is sometimes sepa- 



EMBRYOTOMY 



679 



rated from the body in clumsy and ill-advised efforts to deliver the after- 
coming head. This happens quite frequently in the case of a premature 
or macerated foetus, and if the operator is unprepared for the emergency 
he may find himself in an awkward position. 

The head shotild be fixed at the brim by external pressure. This is 
absolutely essential. If it is not so fixed, every attempt to grasp it or to 



V ./, 



y 





Fig. 414. — Assistant holds handle of the crochet during the use of scissors. 

perforate it simply pushes it away from the brim and the labors of the 
operator are indefinitely prolonged. The bladder should be reemptied 
if necessary. 

While the head is held firmly in position by an assistant the operator 
proceeds with its extraction. If the head is small the task is easy. It is 
only necessary to pass the hand into the vagina and to make traction upon 



680 OBSTETRIC SURGERY 

the lower jaw or, as I recall in one case, to make traction with the finger 
passed through the foramen magnum. 

If the pelvis is contracted, or the head of unusual size, craniotomy or 



A 








Fig. 415. — Extraction of tne fetal body after decapitation. 

even basiotripsy may be performed according to the rules already given, 
the assistant constantly bearing in mind the absolute necessity of keeping 
the head fixed at the brim. 

Evisceration 

In rare cases it is impossible to reach the neck. Here the spinal column 
must be severed at a lower level. It is the thoracic vertebrae that must be 
disarticulated — here one must perforce undertake the gruesome task of 



EMBRYOTOMY 



681 



removing the thoracic viscera in order to make the spinal column accessible. 

Technic. — Strong traction is made upon the arm. This makes the 
axilla accessible, and it is at this point that the opening is made into the 
thoracic cavity. Here again we use the scissors of Dubois, always guided 
and controlled by the internal hand as already described. The opening 
made by the scissors serves to permit the introduction of the hand, and the 
heart and lungs are removed in order to permit greater freedom of manipu- 
lation. The vertebrae are then disarticulated, using the scissors, if pos- 
sible, as involving less shock and traumatism than the crotchet. According 
to Fabre the section is much more 
easily made if directed obliquely 
toward the subclavicular depres- 
sion of the opposite side than if 
made directly transversely. In the 
former case one arm will be 
attached to the upper section and 
one to the lower (Fig. 416). 

In certain cases, fortunately 
rare, the body of the foetus is 
crowded into the lower uterine seg- 
ment and the latter is dangerously 
thinned. The shoulder is entirely 
out of reach. Even to attempt to 
reach the neck would subject the 
distended lower uterine segment to 
dangerous tension. Nothing re- 
mains but to eviscerate the foetus, 
which usually presents by the ab- 
domen or one of the flanks. By 
this manoeuvre the size of the 
foetus is diminished and distention 
of the lower uterine segment les- 
sened. The spinal column may 
now be severed if within easy 
reach. If the task proves difficult, 

1 •, • 1 , , , Fig. 416. — Embryotomy, oblique section. 

however, it is best not to persevere, 

since the evisceration makes the trunk as a whole so flexible that version 
is usually easy (Jeannin). In some cases the back presents. In this case 
it is easy to sever the spinal column and this precedes the evisceration. 
Counter-pressure should not be forgotten. 

Very exceptionally the whole foetus is retained above the ring of 
Bandl, the latter remaining contracted and interposing a serious obstacle to 
the efforts of the accoucheur. The condition may be regarded as a sort 
of hour-glass contraction before delivery. 

If version is impossible, the operator may succeed in reaching the neck 




682 OBSTETRIC SURGERY 

and dividing it by one of the methods already mentioned. If not, his only 
remaining resource is to eviscerate the foetus and disarticulate the spinal 
column wherever it can be most easily reached. Since the foetus occupies 
the thick muscular portion of the uterus, the danger of rupture is less than 
in the case last considered. But the task of dilating the ring of Bandl, 
of severing the fetal trunk and extracting the severed parts, is a long 
and wearisome one, involving a prolongation of the anaesthesia and, as 
a rule, profound shock. 

Cleidotomy 

By this term is meant the division of one or both clavicles. It is 
employed when, in the case of the dead foetus, the head has been born 
but the breadth and bulk of the shoulders effectually prevent delivery. 

Technic. — The head being forcibly extended by an assistant, the 
clavicle is severed by means of long, strong, blunt-pointed scissors. It 
is obvious that the nearer to the sternum it is divided, the more will the 
bisacromial diameter be shortened. According to Edgar this diameter 
may be shortened i^ inches or more by section of the clavicles. 



PART IV 
PATHOLOGY OF THE PUERPERIUM 

CHAPTER XXXH 
PUERPERAL INFECTION 

This ancient enemy of womanhood, now happily disarmed, is nothing 
more nor less than ordinary wound infection, not dififering in cause or 
essential nature from infection as we find it in general surgery. It is, 
however, so modified by location and attendant circumstances that its diag- 
nosis is somewhat more difficult, and its treatment quite different from 
that of other kinds of infection. A clear comprehension of these facts 
at the outset will materially aid the student and practitioner. 

Historical Note. — Various fantastic speculations were indulged in by 
writers of the sixteenth and seventeenth centuries as to the origin and 
nature of this aft'ection. In England, in the latter part of the eighteenth 
century, White and Gordon proclaimed puerperal fever, as it was then 
called, a contagious disease ; and in our own country Oliver Wendell 
Holmes, writing in 1843, eloquently insisted upon this view. It remained, 
however, for Semmelweiss, of Vienna, in 1847, not only to grasp the true 
meaning of puerperal infection, but above all to put his theories into 
practice. His experiments, carried on at the great maternity hospital of 
A'ienna, proved conclusively the truth of his ideas, but like all reformers 
he was subjected to persecution and ridicule, and his discovery was not 
recognized until long after his death. A monument in the church cemetery 
at Budapest gives tardy recognition to one of the world's Immortals. 

The birthplace of antiseptic midwifery in the United States is the 
New York City Maternity Hospital, BlackweU's Island, where the antiseptic 
system was introduced by Garrigues in 1883. Even at this late date he 
was made the subject of reproach and ridicule, nor has he yet received the 
recognition which is his due. Honor to his memory ! 

Frequency. — It is almost impossible to determine the frequency with 
which puerperal infection occurs. The clinical history of the condition 
and the methods of its diagnosis are not well understood. Moreover, 
there is a natural disinclination to accept the diagnosis of infection when 
some other plausible reason can be found for the symptoms. I would not 
assert, as some writers have had the temerity to do, that many physicians 
in private practice willingly practise deception in this matter, while those 
connected with hospitals invariably view their cases with judicial impar- 
tiality. This has not been my observation. There is, however, no doubt 
that hospital records afford the best basis for comparison, since in private 
practice the majority of physicians keep no records at all. 

6S3 



684 PATHOLOGY OF THE PUERPERIU^I 

In the pre-antiseptic period more or less infection was always present 
in the great hospitals, e.g., the Hotel Dieu in Paris and the Vienna 
]\Iaternity, the mortality ranging from 2 to 6 per cent., and in epidemics 
reaching 10 or even 15 per cent. The mortality in well-conducted hospitals 
is now less than i per cent. 

At the Xew York ^Maternity Hospital in the years 1875 to 1882, inclu- 
sive, the mortality ranged from 2.6^ per cent, to 6.67 per cent. In the 
first nine months of 1883 the mortality was still greater, 6.71 per cent. 
On October i Garrigues instituted the antiseptic treatment and during the 
three following months there were 102 deliveries without mortality, which, 
as Garrigues says, seemed at that time "little short of miraculous." In 
the ten succeeding years the total mortality was less than i per cent. 
Surely, there was never a better demonstration of the priceless value of the 
new teaching. 

I am forced to disagree emphatically with those who assert that the 
mortality in private practice is as great as it was in the pre-antiseptic days. 
Certainly this is not true of Xew York and vicinity, especially in the case 
of recent graduates of our colleges and hospitals. Avhom I have had ample 
opportunity to obsen.-e, and who. as a rule, endeavor to apply the principles 
of asepsis. Xor do I often note in their practice cases of virulent infection. 
^Moreover, in former times epidemics were not confined to hospitals, but 
occurred in the outside world as well. Both kinds of epidemics have 
happily disappeared. 

The question has now become one of morbidity rather than mortality. 
The figures are difficult to determine. Considering every rise of tempera- 
ture to 100.4 ^s denoting infection, Btimm estimates the hospital morbidity 
as 20 per cent. This seems to me rather higher than in our hospitals here. 
Perhaps the difference, if difference there be, is due to the fact that in 
Europe trained nursing, as we know it, simply does not exist. 

Classification. — Broadly speaking, all varieties of puerperal infection 
may be classified under two heads, sapr^mia and septicccmia. It is true 
that, from a technical stand-point, this classilication leaves much to be 
desired, since, strictly speaking, sapr^mia is an intoxication rather than 
an infection, and since various obsen-ers, e.g., Bumm, von Franque, and 
\Mlliams, have found streptococci in cases which would clinically be classed 
as sapr^emia. X^evertheless, the division is one of great practical value. 
The majority of cases of infection may be divided clinically into two 
principal classes. In one — sapraemia — the predominating symptoms are 
those of intoxication by putrefactive organisms ; in the other, the clinical 
picture is that of septic infection. These two classes of cases differ 
materially in diagnosis, prognosis, and treatment, and hence present a good 
clinical basis for comparison. The fact that streptococci are found in 
cases of apparent sapraemia is a theoretical, rather than practical, objec- 
tion, since it is evident that in these cases the organisms are not of virulent 
type. Sapraemia is a condition by itself. Septicaemia is multiform in its 



PUERPERAL INFECTION 685 

manifestations. Let us examine these two forms of infection a little more 
closely, first disposing of sapr?emia, and then taking up the classification 
and symptomatolog}- of true septic infection. 

SAPR.EMIA 

Sapr^mia (from the Greek aa-pw^ to decompose), putrid intoxication, 
U^iindintoxikation of the Germans, is by far the most common form of 
puerperal infection. It is the result of the presence in utero of decompos- 
ing animal matter, fragments of placenta, membranes, blood clots, or lochial 
discharge. This decomposition is due to the fact that the saprophytes, 
bacteria of decomposition, have gained access to the uterus. These organ- 
isms are universally present in atmospheric air, and are the cause of 
decomposition as we see it everywhere in dead animal matter. This 
decomposition will occur in the uterus, as elsewhere, if saprophytes are 
admitted to its cavity, just as it will in a can of meat if the lid is removed 
and air with its contained saprophytes is permitted to enter. Just as in 
the can, the contents remain sweet until the cover is removed, so the 
placenta may remain sterile and harmless in titero for weeks if the 
organisms of decomposition do not gain admittance. 

How do they gain admittance ? A lax uterus and wide open cervix are 
predisposing causes. Shreds of membrane hanging from the vulva make 
a ladder by means of which they may ascend from the vagina to the 
uterus. Premature rupture of the membranes allows free entrance of the 
organisms into the uterine cavity even before the completion of labor. 
]\Iore often, in all probability, they are carried upward by unnecessary 
douches or examinations, since they are always present at the introitus 
and about the vulva, and are often found in the vagina. 

Retention of Lochia. — There is another predisposing cause of saprse- 
mia of which mention must be made here — retention of the lochial 
discharge, or lochiometra, as it is called. In these cases the normal 
anteversion of the pregnant uterus is so much exaggerated that the angle 
formed by the body of the uterus and the lower uterine segment is so 
acute that the lochia are confined within the uterine cavity. In some cases 
the distention of the uterus causes severe pain and there is a sharp rise of 
pulse and temperature. The uterus has a " boggy " feel, which has been 
compared to that of pregnancy. The lochia are absent. The symptoms 
usually develop toward the end of the first week and are due partly to 
the reflex influence of uterine distention, and partly to the decomposition 
of retained lochia. If the extreme anteversion is corrected by traction 
on the anterior cervical lip combined with suprapubic pressure, there is a 
gush of foul-smelling lochia and the symptoms are relieved. This con- 
dition should always be borne in mind when symptoms apparently serious 
develop toward the end of the first week. 

Clinical History of Sapraemia. — Let us suppose that we have before 
us a fairly well-marked case. Three or four days after deliverv the 



686 PATHOLOGY OF THE PUERPERIUM 

patient complains of headache, which is often a prominent symptom, and 
the temperature rises to 102 or 103 degrees. The chilly sensations that 
usually go with rising fever are present, but there is, as a rule, no distinct 
chill. The pulse is not very rapid, perhaps 100 to no. Palpation shows 
that the fundus is higher than it should be and the uterus larger, but there 
is no great tenderness, or " bogginess," as in the case of the more severe 
forms. The lochia are abundant and have a foul odor. The cervix is 
patulous and easily admits one or even two fingers. The cavity of the 
uterus contains ill-smelling debris, placental fragments, shreds of mem- 
brane, or decomposing clots. The face is often darkly flushed and the 
expression one of discomfort and annoyance rather than of serious illness. 
The clinical picture here presented is a typical one, but the picture may 
vary. Now and then there may be a severe chill at the outset and the tem- 
perature may reach 104. More often, there is but little fever, 100 or loi, 
and even this may last only for a day or two, the Eintagsfieber of the 
Germans. The red lochia are abundant, and after-pains are likely to be 
present with the discharge of ill-smelling clots. The duration of an attack 
of saprsemia varies from a few days to a week or even more, but with 
proper treatment the symptoms usually disappear in a few days. Very 
often there is but little fever, 100 or loi, and even this may last but a day 
or two. 

Puerperal Septicemia (Bacter.^mia) 

Septicaemia differs from saprsemia fundamentally in that the offending 
organisms have the power of reproducing themselves to an indefinite 
degree, of entering the lymphatics and the general circulation, and of 
migrating to distant parts of the body, there to continue their unhappy 
work. Thus we see that septicaemia is, or at least may become, a general 
disease, while saprsemia is a local condition. 

By far the most frequent offender is the streptococcus, familiar to 
every student as the cause of erysipelas, pyaemia, septicaemia, etc. 

Other pyogenic organisms less frequently found are the staphylococcus, 
the gonococcus, the colon bacillus, and the pneumococcus. 

There is no reason why puerperal wounds, like other wounds, should 
not become the nidus of any infectious germ, and so we have as curiosities, 
occasionally encountered, cases of infection by the bacillus of tetanus, the 
typhoid bacillus, the diphtheria bacillus, the bacillus of tuberculosis, etc. 

Strictly speaking, all these conditions do not come within the definition 
of puerperal septicaemia. For example, the colon bacillus and the bacilli 
of tetanus and diphtheria occupy a middle position. They possess only 
moderate invasive properties, do not usually travel farther than the outer 
layers of the wounds which they infect, and, like the saprophytes, affect the 
organism by the liberation of their toxins, rather than by themselves 
invading distant localities. 

The same thing may be said of infection by the gas bacillus {Bacillus 



PUERPERAL INFECTION 687 

acrogencs capsiilatus) , the organism which is the cause of tympania uteri. 
This organism,, though usually behaving as a saprophyte, may occasionally 
produce a true septicaemia. 

It seems better, however, to include infections by these organisms in 
the categor}^ of puerperal septicaemia, since they offer a more serious 
prognosis than does pure sapraemia. 

Etiology. — In the birth canal, as elsewhere, wound infection may be 
caused by the presence of any one of a large number of microorganisms ; 
or the infection may be of the mixed variety, two or more organisms being 
present.- We have already discussed the role of the saprophytes in the 
production of sapr^emia, but we still have to deal with the larger and more 
complex subject of septicaemia. 

Let it be understood at the outset that puerperal infection is not a 
specific disease, and that there is no specific organism concerned. Here, 
however, as in general surger}^, the streptococcus is by far the most fre- 
quent offender. This is already known to the reader as the cause of 
erysipelatous inflammation, of most abscesses, and of suppuration in 
general. Next in order of frequency come the gonococcus and staphylo- 
coccus, in the order mentioned, and at a much greater distance the colon 
bacillus and the pneumococcus. 

How do the bacteria gain access to the puerperal wounds ? 

By contact, as in other varieties of wound infection. The sources of 
contact are the hands of the accoucheur, or nurse, instruments and dress- 
ings that are not sterile, fecal contamination, the unskilled interference 
of abortionists and midwives, copulation at or near the time of labor, 
douches carelessly or improperly given, tub-bathing just before or during 
labor, etc. 

Doubtless the hand, as the instrument most often used, and the most 
difficult to disinfect, is the usual medium of infection. Next would come 
instruments and dressings, and, much less frequently, the various irregular 
and uncommon varieties of septic contact that defy orderly arrangement. 
The one important thing to remember is that in practically all cases the 
infective material is introduced from without, and that therefore puerperal 
infection is a preventable disease. 

The uterus after delivery, with its warmth and moisture, its raw 
surfaces, and its necrotic content, seems to afford ideal conditions for 
bacterial development. Our methods of disinfection are, at the best, 
imperfect, and are in some cases, it must be admitted, carelessly applied. 
Moreover, many cases do well in which no precautions whatever are taken. 
This of course is no excuse for carelessness, but it indicates that we should 
study and respect the methods of nature in limiting infection. 

What these methods are, we know only in part. That they exist, how- 
ever, is beyond all doubt. Konig has shown that the acid secretion of the 
vagina is antagonistic to the germs of infection. Doubtless the flushing 
of the birth canal with blood and liquor amnii, which follows everv labor. 



688 PATHOLOGY OF THE PUERPERIUM 

performs the part of an aseptic irrigation. Then, too, the contraction of 
the uterus which normally follows delivery empties the organ of all debris 
and, if continued, keeps it empty. 

These facts afford useful therapeutic hints which are considered 
elsewhere. 

The bacteriology of the vagina has been the subject of much careful 
study of late years, notably by Doderlein, Konig and Menge, in Germany, 
and in our own country by Whitridge Williams, but the results have been 
variable. Williams holds, as the result of his work, that pyogenic cocci are 
not normally found in the vagina of pregnant women, and that the only 
pyogenic coccus that can flourish in the vaginal secretion is the gonococcus. 

Personally, I believe that Williams is correct in this matter, for it seems 
impossible to avoid the belief that, if pyogenic cocci were normally present 
in the vagina, puerperal infection would be far more common. ]\Ioreover, 
we know from experience that in gonorrhoeal cases infection will not 
infrequently occur even though the labor be conducted in an aseptic manner. 

But this is not auto-infection, since the gonococci, of course, came 
originally from without. This also applies to possible cases of interstitial 
endometritis existing before pregnancy (Hirst), and rupture of an old 
pyosalpinx during labor. 

Even if pyogenic organisms are found in the vagina, it would seem that 
they must, for the most part, have lost their virulence. 

Franz and others believe that anaerobic saprophytes are normally pres- 
ent in the vagina and may, under certain circumstances, make their way 
into the uterus and cause fever of a mild type, lasting only a day or two, 
even when there has been no internal manipulation or penetration of any 
kind. The nature of these organisms is by no means well understood, nor 
has their infectious character been proven, and from w4iat we know of 
nature's conservative processes in normal labor, the idea of an infectious 
property in physiological maternal secretions seems a priori improbable. 

The identity and influence of the various organisms which are found 
in the birth canal have recently become favorite subjects of study, and a 
great mass of literature has accumulated which it would be unprofitable 
to attempt to review here. It is noticeable that the. subject has so engaged 
the attention of many writers, that they have neglected the serious clinical 
study of the various types of infection with reference to diagnosis and 
treatment. 

The student and practitioner are apt to become bewildered in trying 
to draw practical conclusions from a mass of miore or less reliable data, 
and the effort to remember too much often results in the lack of any 
knowledge of the subject. 

The following facts seem to me to be well established : 

I. That in the vast majority of cases the birth canal does not contain 
virulent cocci, and that if such organisms do gain entrance to the vagina 
they are best dealt with by the forces of nature. 



PUERPERAL IXFECTIOxM 689 

2. That puerperal infection is usually streptococcus infection. 

3. That, with the exception of gonorrhoeal cases, infection almost 
always comes from without, and that the possibility of auto-infection in 
the strict sense of the term has not been proven. 

4. That in view of the marked difference of opinion among bacteriol- 
ogists, clinical experience must, as heretofore, remain the final test in 
matters of diagnosis and treatment. 

Classification. — The common method of classifying the different varie- 
ties of puerperal infection according to their location or, so to speak, 
topographically, beginning at the vulva and going on from vulvitis to 
vaginitis, cervicitis, endometritis, etc., has always seemed to me a very poor 
one — one which would only occur to the purely library or laboratory 
student, and which seems grotesque and unnatural to the man who spends 
much time in the hospital ward or the lying-in chamber. It certainly gives 
to the inexperienced a wrong perspective, and leads the student to an 
entirely incorrect view of the relative frequency and importance of the 
dift'erent varieties. One does not usually find ocular demonstration of 
puerperal infection by inspecting the vulva. The matter is not as simple 
as that. 

Let us then begin our observations where infection usually begins, i.e., 
at the endometrium, or, to speak still more definitely, at the placental site. 
Here is a raw surface freshly denuded, here are sinuses that open into 
the general circulatory stream, here are the lymphatic channels that lead to 
the parametrium and the general peritoneum. 

Puerperal infection, as we see it in the everyday practice of medicine, 
and especially as the general practitioner most often sees it, begins as a 
putrid endometritis (saprsemia) or as a septic (usually streptococcic) 
endometritis. Doubtless it is usually, at the last analysis, a mixed infection, 
since in sapraemia, streptococci, though not of a very virulent character, 
are often present, and streptococcic infection is often complicated by the 
intrusion of the omnipresent saprophytes. At the bedside, however, the 
distinction is usually plain enough. 

It is true that tears of the perineum and vagina do not always heal 
by first intention, but this delay in healing, while technically it may consti- 
tute puerperal infection, since it is the infection of a puerperal wound, 
has, as a rule, little or no effect upon the general condition. Pulse and 
temperature remain unaltered. The thick mucous membrane of the vagina 
has little absorptive power, and convalescence is not materially delayed. 
The uterus is not specially enlarged or tender and the appetite and general 
condition are good. The vaginal discharge is increased, and the proximity 
of the saprophytes insures a foul odor. The inflammation may be simply 
<:atarrhal in character, as indicated by redness and abundant secretion, 
or it may be diphtheroid in character, i.e., the affected surface, usually 
the site of an unhealed perineal tear, is covered with a grayish, false 
membrane, consisting of necrotic tissue separated by a granulation layer 
44 



690 PATHOLOGY OF THE PUERPERIU:\I 

from the sound tissues underneath. This was formerly an everyday occur- 
rence in hospitals — ^^the puerperal ulcer of the older writers. One seldom 
sees it nowadays. 

As a rule, these local infections involve little or no danger, though 
mistaken zeal in treatment may carr}^ the infectious process to the endo- 
metrium, and thus work incalculable harm. 

Saprasmia we have already considered. Generally speaking there is but 
one variety of saprsemia, different cases differing in degree rather than in 
kind or location. It is true that saprophytes about the vulva or in the 
vagina may lend a bad odor to the lochia, but in these cases the general 
condition is affected vers^ little or not at all. 

The guiding principle to be observed in any scheme of classification 
is the fact that the saprophytes confine their activities to the uterine cavity. 

In septicaemia, on the other hand, the organisms have invasive proper- 
ties which may cause the extension of the infective process beyond the 
birth canal. This extension may occur by means of the lymphatics, the 
veins, and rarely, as in salpingitis, by the mucous membrane ; or, in other 
words, by " continuity of tissue." 

In the great majority of cases infection is transmitted by way of the 
endometrium. There is one important exception which the reader should 
not overlook. Infection, as we shall presently see, is often transmitted 
directly to the parametrium through the medium of a cervical tear, and 
by way of the lymphatics of the broad ligament. 

Including then, for the sake of convenience, the condition which we 
call sapraemia, and which is an intoxication rather than an infection^ we 
may classify the different forms as follows : 

EXDOMETRITIS 

Let us now consider a typical case of true septic endometritis. Symp- 
toms that attract attention usually appear on the third or fourth day after 
delivery, but careful observation will show that there is often a subfebrile 
temperature of lOO or loo)^ as early as the second day, and that even at 
this time there is a moderate acceleration of the pulse. The scene opens, 
usually, with a well-marked chill, which is followed by a high temperature, 
103 or 104, and a rapid pulse, 120 or 130. The rapidity of the pulse is the 
most significant of all the symptoms and is in striking contrast with the 
comparatively slow pulse of saprjemic infection. The face is pallid rather 
than flushed. The patient looks seriously ill, but does not complain of 
pain, in fact, often expresses herself as feeling quite well. 

Locally the symptoms are not marked at first. Involution does not 
progress and the fundus remains high, but there is no great tenderness on 
pressure. ^lassage of the uterus does not, as usual, produce contractions. 
The lochia are at first abundant, but soon lose their bright red color and 
become mixed with a purulent discharge. If high temperature persists, 
the discharge becomes scanty or even disappears altogether. In cases of 



PUERPERAL INFECTION 691 

pure streptococcic infection there is little or no odor to the lochia. The 
cervix admits the finger but is not as soft and patulous as is the case in 
sapr^emia. The uterine cavity is empty. Bacteriological examination 
shows the presence of streptococci in the uterine lochia. 

The further course of the disease depends upon the virulence of the 
infective organisms. In some cases, now happily rare, the general con- 
dition becomes rapidly worse and the patient dies in a few days as the 
result of a profound toxaemia. 

^lore commonly the process becomes localized in the uterine wall as a 
metritis. In any case of severe and long-continued endometritis, one 
suspects involvement of the uterine wall, if the uterus becomes large, 
boggy and sensitive, and especially if there is a profuse purulent discharge. 
All the structures of the uterus may be involved. Large areas of mus- 
cular tissue may slough away (metritis dessicans of Garrigues) or 
abscesses may form beneath the peritoneal covering of the uterus, where 
the lymphatic supply is richest, with resulting adhesions, and attachment 
of the uterus to the intestine or abdominal wall. Both these occurrences 
are rare, however. More commonly there is simply a moderate infiltration 
of the uterine wall with leucocytes. 

SALPINGITIS 

Extension of the infectious process from the mucous membrane of the 
uterus to that of the tube by " continuity of tissue " would seem a very 
natural result, but as a matter of fact it does not occur as often as one 
would suppose. Bumm advances the not unreasonable hypothesis that 
the inflammatory swelling of the endometrium seals up the minute uterine 
aperture of the tube, thus preventing the entrance of the streptococci. 
Infection may be communicated to the tube through the lymphatics. In- 
flammation and even abscess of the ovary (oophoritis) may also occur, 
usually, however, as part of a parametritis. In rare instances a ruptured 
follicle is directly infected by contaminated peritoneal fluid. 

The local symptoms are most prominent. There are pain and rigidity 
at one side of the uterus, and internal examination discloses an extremely 
sensitive mass in one or the other cul de sac. General symptoms are for 
the most part lacking. There may be evidences of peritoneal irritation, 
e.g., distention, vomiting, and peristaltic arrest, but these soon disappear. 

PARAMETRITIS 

Much more common than salpingitis is parametritis, by which is meant 
the inflammation of the peri-uterine connective tissue. Here again the 
infection is transmitted through the lymphatics, which lead directly from 
the uterine waU to the connective tissue of the parametrium and the broad 
ligaments. In many cases, probably in the majority of cases, the infection 
is transmitted directly to the parametrium through a cervical tear, and not 



692 PATHOLOGY OF THE PUERPERIU:^! 

secondarily through the endometrium, but in both cases the lymphatics are 
the avenues of infection. 

The symptoms usually appear about the third or fourth day, more 
rarely about the eighth or tenth. AMien they appear early they are usually 
due to a cervical tear. AA'hen later, they are secondar}\ and sometimes 
the result of unskilled or improper manipulations, e.g., curettage, douches, 
and digital examinations, which reopen avenues of infection and defeat the 
efforts of nature to limit its extension. Leaving the bed too early is an 
occasional catise. 

The first symptoms may be such as to excite much apprehension and 
may even lead the attendant to fear the development of a general peritonitis. 
There is often a chill followed by a temperature of 103 or 104 and a rapid 
pulse. 120 or more. There are also abdominal pain and distention, with 
perhaps vomiting, retention of tirine. and peristaltic arrest. The pain, 
however, soon becomes localized at the side of the uterus, the threatening 
symptoms subside, and internal examination shows increased resistance at 
one side of the vaginal vault. 

This increased resistance gradually develops into a well-marked exu- 
date. The uterus is pushed over to the opposite side and loses its natural 
mobility. In rare cases the process involves both sides and the uterus is 
solidly fixed in a mass of exudate. 

The further course of the disease depends upon whether the morbid 
process in the parametrium tmdergoes resolution, or goes on to suppura- 
tion. Fortunately the former is more common. In cases of resolution 
the high temperature may continue for from one to three weeks. Xot 
longer than this, as a rule, unless the case goes on to suppuration. There 
are usually morning remissions, at least after the first few days. As time 
goes on, these remissions become more marked and there may even be an 
evening fever with normal temperature in the morning. This fact should 
never be forgotten, for. as was long ago noted by Lusk. if the physician 
does not see his patient in the evening, he may be under the impression 
that she has no fever at all. 

Pus formation is indicated by chills, fever, and night-sweats. The 
tumor becomes more sensitive and softer. The pus may burrow in various 
directions. It is most likely to follow the pelvic connective tissue beneath 
the peritoneum of the anterior abdominal wall, appearing finally above 
Poupart's ligament, or in the connective tissue behind the cervix, or about 
the rectum. Recalling anatomical relations, the reader will remember 
that the connective tissue at the sides of the uterus is continuous with 
that in these locations. The abscess may point above Poupart's ligament, 
or, what is more common, the pus may gravitate downward and make its 
escape by way o " the rectum, bladder or vagina. 

Pus formation, however, is not limited to these situations, nor do the 
bacteria always regard anatomical limitations or follow the prescribed 
paths of least resistance. Xow and then the pus dissects its wav behind 



PUERPERAL INFECTION 693 

the pubes and far up into the abdomen, the abscess " pointing " near the 
navel, or a psoas abscess may result, pointing below Poupart's ligament or 
even down the thigh. 

In the pre-antiseptic days, when no precautions at all were taken, these 
abscesses were common enough. Now, happily, they are seldom seen. 
]\Iany men in active practice there are who have never seen them at all. 

The precautions now taken apparently diminish the virulence of the 
infecting organisms, even when they do not destroy them. In many cases 
the process is limited to a simple inflammatory oedema, the first stage in 
phlegmonous inflammation, which disappears in a week or so. Even if the 
process goes on to extensive exudation, the exudate is often absorbed. 

PERIMETRITIS OR PELVIC PERITONITIS 

It does not seem probable that an inflammation of the pelvic cellular 
tissue can exist without some accompanying involvement of the pelvic 
peritoneum. If, however, the latter is chiefly involved, the symptoms of 
peritonitis will predominate. In pelvic peritonitis the local signs are less 
prominent though by no means absent, but the general symptoms are, for 
a time at least, more ominous and severe. The initial chill is more pro- 
nounced, and the small wiry pulse of peritonitis at once attracts the 
attention. The fever is continuously high, i.e., without the marked morning 
remissions of parametritis, vomiting may occur, and there may be some 
of the local evidences of peritonitis, e.g., constipation followed perhaps 
by diarrhoea, retention of urine, and moderate abdominal distention. 
There may be marked sensitiveness to pressure in the lower abdomen, but 
evidences of tumor formation are not necessarily noted until the end of 
the first week. 

The exudate in perimetritis is at a higher level than in cellulitis and 
is more central or bilateral. It can be palpated along the pelvic wall 
through the lower abdomen as a mass, characteristically irregular in out- 
line. Internal examination shows that it is posterior to the cervix rather 
than to one side of it. Often it seems to surround the cervix in such a 
way that one cannot tell where cervix ends and uterus begins. 

A significant sign is that noted by Garrigues, viz., that in the case of 
peritoneal exudate one can pass the fingers between the exudate and 
the pelvic wall, while the exudate of a cellulitis does not permit such 
introduction. 

These are the chief diagnostic points, but the reader must not expect 
them to be well-marked in all cases, since the two conditions are so closely 
combined. The matter is of interest from a scientific, rather than a 
practical, stand-point, since there is little or no difference in the treatment. 

If the patient has a bad cervical tear the condition is probably a 
parametritis. 

The exudation in pelvic peritonitis does not usually become the seat of 
suppuration, and the symptoms usually subside within two or three weeks. 



694 PATHOLOGY OF THE PUERPERIUM 

but even here suppuration may occur. The subsequent effect, however, 
is more unfavorable than in celhilitis. These patients often suffer from 
chronic disease of the appendages — the aftermath of a gonorrhoea. The 
great majority of cases of pelvic inflammation appearing late in the 
puerperium are of gonorrhoea! origin. 

GENERAL PERITOXITIS 

When the organisms are of very virulent type, the leucocytic barriers 
erected by nature are absent or inefficient, and the infection may extend 
to the general peritoneum. It is plain that the localization of the infectious 
process in the pelvic peritoneum is to be regarded as favorable; at least 
as far as the danger of death is concerned. 

It is hardly necessary to rehearse here the symptoms of diffuse peri- 
tonitis already familiar to the reader. Characteristic of the puerperal form 
is the early appearance of the symptoms, usually vi^ithin three or four 
days, and sometimes within a day or two, after delivery. The initial chill 
is long and severe, and the temperature is high, 104 or thereabouts. The 
small, rapid pulse, which is 120 from the start, warns even the careless 
observer that something serious is in progress. Soon the abdomen becomes 
distended and exquisitely tender, the descent of the diaphragm becomes 
restricted and painful, and the respirations much increased in frequency. 
The reflex disturbances resulting from overwhelming peritoneal irritation, 
e.g., that most distressing symptom, constant vomiting and hiccough, 
constipation followed by diarrhoea, and sometimes retention of urine, 
combine to render the lot of the poor sufferer unbearable. He who has 
once witnessed this picture will think no precautions thrown away in an 
effort to prevent the possibility of its occurrence. 

ACUTE SEPSIS (septicemia LYMPHATICa) 

This is the most virulent of all the forms of infection. Its only redeem- 
ing feature, if such a process can be said to have a redeeming feature, is 
that pain is not a prominent symptom. Here the organisms pass directly 
into the circulation through the lymphatics, and there are no distinct evi- 
dences of localization. A futile eft"ort at resistance on the part of nature 
is shown in the so-called lymphatic peritonitis, a beginning or abortive 
peritonitis, and similar manifestations are found in the pleura and peri- 
cardium, and in the synovial membranes of the large joints. Abscess 
formation does not occur. Bacteria are found in the blood in large 
numbers. There is cloudy swelling of the parenchyrra of the viscera. 
This form of infection was a feature of the terrible epidemics that were 
observed in hospitals in pre-antiseptic times. It is now a rarity. 

The initial chill is long and severe and the temperature is continuously 
high. There are no remissions. In some cases, however, the temperature 
is normal, or even subnormal. The pulse is high. 120 or more, and soon 
becomes weak. The face is pale, sometimes jaundiced. Often the pallor 



PUERPERAL INFECTION 695 

is such that the patient looks as though she had had a hemorrhage, though 
the blood loss may have been but slight. The respirations are rapid, and 
there is a certain amount of dyspnoea, though not of the distressing kind 
that accompanies general peritonitis. Here the dyspnoea is the result, not 
of mechanical obstruction, but of the destruction of the red blood- 
corpuscles by the toxins. Sleeplessness, probably due to cerebral anaemia, 
is a prominent symptom. There is little or no pain and the mind is usually 
clear. Sometimes, indeed, the patient avows that she feels perfectly well 
( euphoria V. though the pallor of the face and, above all things, the weak 
and rapid pulse speak otherwise to the experienced observer. 

In contradistinction to the gravity of the general symptoms the local 
symptoms are slight. There may be moderate distention of the abdomen, 
but there is no special pain or tenderness. The lochial secretion is sup- 
pressed, and milk does not appear in the breasts. A rapidly fatal ter- 
mination is the rule, death occurring perhaps in two or three days. 

PUERPERAL PY.EMIA ( SEPTIC PHLEBITIS, SEPTICEMIA VENOSA) 

In this condition the bacteria enter the circulation, not by means of 
the lymphatics, but through the venous system. The first step in the 
process is a metrophlebitis, i.e., an inflammation of one of the uterine or 
pelvic veins. This in turn is caused by infection of a thrombus in the vein. 
Of course, thrombosis is not normal, but it is by no means uncommon, 
especially in cases of relaxed and flabby uterus. In such cases the walls 
of the sinuses at the placental site are not brought into contact, as in a 
well-contracted uterus, and the normal mechanism of thrombus prevention 
is absent. For the same reason, probably, pyaemia often follows infection 
which begins during labor, e.g., after premature rupture of the membranes. 

Of course, the infection of the thrombus usually occurs at the placental 
site. Hence it is, no doubt, that this variety of infection is most often 
noticed after placenta praevia, in which there is of necessity much manipu- 
lation about the placental site, and after the manual removal of the placenta 
or its prolonged retention. But these are not necessary to its production. 
It may follow a mild septic endometritis of uncertain origin and almost 
unnoticed symptoms. 

Of course it is theoretically possible for a vein to be infected, because 
it is surrounded by infected tissue. In this case there is a proliferation 
of the endothelium with resulting thrombosis, but experience teaches us 
that thrombosis is not usually caused in this way. 

Perhaps thrombosis is to be regarded as an effort of nature to prevent 
infection. At all events post-mortem examination has confirmed clinical 
experience, in showing that, as a rule, the thrombi at the placental site are 
but little affected even when the endometrium is the seat of severe 
inflammation. 

Symptoms — This form of infection presents a very definite and 
characteristic clinical picture. It is, however, so insidious in its onset. 



696 PATHOLOGY OF THE PUERPERIU:\I 

and so deceptive in its course, that mistakes are often made. Hence it is 
obvious that it should be well studied by student and practitioner. 

Unless the patient is in a hospital, or at all events unless the tempera- 
ture is regularly taken, the early stages of the affection are usually over- 
looked. If, however, the case is carefully observed, a slight evening rise 
of temperature is observed after the first few days. It is not until about 
the end of the first week, or perhaps in the course of the second week, that 
serious symptoms become manifest. At this time the disease is announced 
by a well-marked chill followed by a high temperature, 104 or even higher. 
This in turn is succeeded by a profuse sweat, after which the patient seems 
to recover, and for a variable time feels as well as ever. The whole process 
reminds one strongly of an acute malarial attack, for which, indeed, it has 
many times been mistaken. The patient now seems to have recovered. 
The temperature and pulse are again practically normal, the appetite 
returns and the physician perhaps congratulates himself upon the prompt 
recovery of the patient. This deceitful truce, however, is of short duration. 
After a day or two another chill follows, and the same process is repeated. 

Meanwhile local examination reveals little or nothing. The uterus is 
normal in size, and there is no tenderness on pressure. Involution appears 
to go on as usual. Slight tenderness and a doughy resistance may be felt 
over the affected vein, according to Bumm. Personally, I am inclined to 
believe that it is well to refrain from much manipulation, either external 
or internal, in these cases, on account of the danger of detaching a bit of 
the thrombus, thus leading to renewed infection, or possibly to embolism 
and sudden death. 

Meanwhile, with recurring chills and sweats, the general health becomes 
affected. It is probable, though hardly susceptible of positive proof, that 
these chills represent the discharge of fragments of disintegrated thrombi, 
with their bacterial content, into the blood stream. At all events, examina- 
tion of the blood during or shortly after a chill shows the presence of the 
organism. 

Sooner or later the temperature remains somewhat elevated during the 
intervals. The intermittent fever has become remittent. The blood 
gradually becomes impoverished, the face pallid or jaundiced, the urine 
is scanty and contains albumen. The pulse is rapid and weak. In bad 
cases the dyspnoea, already mentioned in connection with acute sepsis, is 
present, but here it is a late, not an early symptom. It will be noticed that 
toward the end the symptoms are in fatal cases much the same as in acute 
sepsis, and here as there the toxins benumb the sensibilities. Nature 
herself seems to provide an anaesthetic for the cases that cannot be cured. 

Most cases are complicated by metastatic processes, which may occur 
in any part of the body. This is easily explained, when we recall that 
fragments of disintegrating thrombi may at any moment be carried along 
with the venous current to distant organs and tissues. Thus we may have 
septic endocarditis, pneumonia, empysemia, hydronephrosis, etc. The 



PUERPERAL INFECTION 697 

glands may become affected, as in thyroiditis and parotitis, and there may 
be abscesses of the tonsils as well as abscesses of the subcutaneous 
connective tissue in any part of the body. 

Of course, these metastases do not always take the form of abscess 
formation. Sometimes the process may be one of necrosis of the endothe- 
lium, fibrinous exudation, as in endocarditis, or serous exudation, as in 
the milder cases of synovitis. 

It is obvious that to discuss all the occasional or possible complications 
of puerperal pyaemia would be impracticable as well as unnecessary. It 
must suffice here to mention briefly a few of the most common or 
characteristic. One of these is puerperal septic endocarditis. 

Puerperal Septic Endocarditis 

The bacteria in the blood stream have a tendency to collect upon the 
cardiac valves. Just why is not altogether clear. The left side of the 
heart is usually affected. Pre-existing endocarditis has been adduced as a 
predisposing cause, the bacteria collecting upon the valvular vegetations. 

Symptoms. — Whatever the cause may be, the condition is sufficiently 
definite. The temperature remains high for the same reason that it does in 
acute sepsis, i.e., because the bacteria are constantly discharged into the 
circulation and the toxins are constantly renewed in full measure. The 
pulse is rapid and dicrotic, and cardiac murmurs are usually heard, though 
they may be absent. Cerebral symptoms, headache, stupor, and even 
convulsions, are prominent, as might be expected, and the patient may die 
with symptoms of meningitis. A sad result, happily rare, is loss of vision 
from hemorrhage into the retina. Even panophthalmitis may occur with 
complete destruction of the eye. 

The reader should remember that endocarditis may also occur in acute 
sepsis. 

Metastatic abscesses are most common in the lungs and kidneys. A 
large embolus may block a large branch of the pulmonary artery and cause 
sudden death. Small fragments may cause only a temporary, though 
terrifying, asphyxia, followed by haemoptysis. A purulent embolus 
deposited in the lung naturally leads to a secondary pneumonia, the so-called 
septic pneumonia. The physical signs are not typical but with care they 
can be found. The cause is not far to seek. " Pneumonia " in the 
puerperium is to be regarded with suspicion. 

Purulent emboli in the kidney give rise to pus, blood and albumen in 
the urine and pain in the lumbar region, in fact, to the usual symptoms of 
hydronephrosis. 

Septic Arthritis 

The effusion may be either serous or purulent. The large joints are 
most often affected, usually the knee. 

Diagnosis. — The diagnosis of pyaemia is more difficult than that of 
other varieties of infection. In the first week there mav be no other 



698 PATHOLOGY OF THE PUERPERIUM 

symptom than an evening temperature of perhaps 99.5 to 100.5. Here 
we have an illustration of the importance of taking the temperature 
regularly in all puerperal cases. If in a given case there is a slight evening 
fever during the first week, and especially if there is a history of any of 
the predisposing causes of pyaemia, e.g., placenta praevia, or intrapartum 
infection, the attendant should be on his guard. 

After one or two chills have occurred, the condition can hardly be 
mistaken for anything except intermittent malarial fever, which it resem- 
bles very closely. The latter as a complication of the puerperium is 
certainly very rare in New York and vicinity, but is not uncommon in 
other sections of our country. In the case of malaria, however, the blood 
will show the plasmodium, and improvement will follow the administration 
of quinine. 

Prognosis. — Pyaemia infection, while offering a more favorable prog- 
nosis than acute sepsis, is always a serious condition, and even when 
recovery occurs it is usually only after a long illness. If some vitally 
important organ is involved the prognosis is, of course, much more serious. 
Endocarditis is usually fatal, and abscess of the lung, kidney, or liver, of 
course, highly dangerous. 

PHLEGMASIA ALBA DOLENS ( FEMORAL PHLEBITIS, MILK LEG) 

This condition is still popularly called milk leg and was once supposed 
to be due to metastasis of milk from the breasts. In reality it is an 
extension of the thrombotic process from the pelvic veins to the femoral 
vein ; in other words, a femoral phlebitis. The old term phlegmasia, how- 
ever, has become so imbedded in the literature of the subject that it is not 
likely to be displaced. 

Properly speaking, femoral phlebitis is merely a division of the general 
subject of puerperal pyemia, but it has a distinctive symptomatology of 
its own, and for this reason is better considered separately. 

The condition hardly ever goes on to suppuration, but there is usually 
sufficient phlegmonous inflammation to cause severe pain and marked 
tenderness on pressure in the femoral region. The veins may be palpated 
and recognized. The diagnosis is sufficiently easy without much handling 
of the parts, and this should be avoided on account of danger of embolism. 

The symptoms of phlegmasia are both general and local. The general 
symptoms are at first the same as those that precede other forms of pyaemia, 
a slight evening rise of temperature often overlooked. These symptoms 
may subside altogether for a time, when in the second, or perhaps even the 
third, week the temperature again rises, perhaps to 103 or 104, the pulse 
becomes rapid, and severe pain in the femoral region with beginning 
swelling of the leg makes the diagnosis certain. The whole thigh and leg 
become swollen, smooth, rather firm, and of a milk-white color. The 
swelling usually begins at the ankle, and extends upward. The duration 
of this troublesome and painful affection is from four to six weeks. 



PUERPERAL INFECTION 699 

There is another and much less common form of phlegmasia which is 
secondary to a pelvic cellulitis, and in which the swelling begins in the 
neighborhood of Poupart's ligament and extends downward. 

There is also an aseptic thrombosis that may complicate the lying-in 
period, and may even occur before delivery. Predisposing causes are 
pressure of the pregnant uterus upon venous trunks, relaxation of the 
uterus, pelvic varicosities, etc. In these cases fever is absent and the condi- 
tion is usually overlooked. There may or may not be more or less oedema 
and swelling of the leg, depending upon the location of the thrombus. 
]\Iahler has shown that in some cases the only symptom is a persistently 
rapid pulse, otherwise unexplainable. This is a very important clinical 
fact that should never escape the attention of the attendant, for in these 
cases there is always the danger of embolism. The rapidity of the pulse 
probably represents the effort of the heart to overcome the obstruction 
to the circulation. 

The left leg is more commonly affected than the right, doubtless because 
of the greater frequency of varicosities in this member. Now and then 
both femoral veins are the seat of thrombosis and both legs are swollen. 
This, however, is fortunately rare. 

The question has occurred to many, " Why does the thrombosis so 
often occur in the femoral rather than in other veins? " Widal's theory, 
that it is because the return current of blood is slowest at that point, 
especially when the patient first leaves her bed, seems satisfactory. 

The treatment will be considered in connection with the general 
treatment of puerperal infection. 

Diagnosis of Puerperal Infection. — The existence of fever during 
the lying-in period should be regarded as presumptive evidence of infection, 
unless it can be definitely accounted for. In this way we may occasionally 
make a diagnosis of infection when none exists, but if the attendant has 
sufficient experience and judgment to refrain from unnecessary operative 
treatment, or intra-uterine manipulations, no harm will be done. On the 
other hand, the increasingly favorable reports of the results of the serum 
and, occasionally, of the vaccine treatment, together with their apparent 
harmlessness, make it highly desirable that no time should be lost in cases 
of serious infection. 

We should remember, however, that puerperal women, like other 
women, are subject to various causes of fever other than infection. I 
recall the case of a hospital patient who had been subjected to many 
examinations and diagnostic tests, including aspiration of the breast for 
pus, without result. An alveolar abscess finally revealed itself as the 
cause of the trouble. It was a case for the dentist, not the obstetrician. 
Now and then one finds a man so occupied with the idea of infection that 
he overlooks an influenza or a tonsillitis that could not possibly escape 
his notice at any other time. 

The most common cause of non-septic fever in the puerperium is con- 



700 PATHOLOGY OF THE PUERPERIUM 

stipation. The pulse is usually slow. The condition is promptly relieved 
by a cathartic. 

Extreme distention of the breasts about the third or fourth day is a 
source of great discomfort to certain nervous and sensitive patients, and 
may be cause of fever, which disappears as soon as the breasts are emptied 
either by the baby, the breast pump, or massage. 

Extreme mental and nervous excitement may now and then cause fever 
in hysterical and neurotic subjects, and these may also have disturbed 
cardiac action and rapid pulse, which serve to increase the anxiety of the 
attendant and the difficulty of diagnosis. Here, however, the history and 
demeanor of the patient, knowledge of the attendant circumstances, and the 
absence of all local signs of infection will aid in the diagnosis. Aloreover, 
the condition is usually of short duration. 

The possibility of intercurrent disease should not be forgotten, and in 
all doubtful cases a careful examination should be made. This should 
include auscultation of the chest, inspection of the throat, and examination 
of the blood for the bacillus of typhoid, the plasmodium of malaria, and 
in suspected cases for the spirochseta pallida of syphilis. 

If one would be in line with progress and employ modern methods, 
bacteriological examination should not be forgotten. This embraces 
examination of the lochia and of the blood. 

Bacteriological examination of the lochia alone is, to my mind, of 
theoretical rather than practical value. The mere presence of the bacteria 
does not necessarily mean much. It is a question of virulence rather than 
presence. Various kinds may be present in the same patient, and non- 
virulent streptococci are often found in the case of patients who present 
no symptoms of infection. ^Moreover, accomplished bacteriologists differ 
as to methods of technic. Kronig now believes that, using blood-agar 
as a culture, he can get positive results, but according to Zangemeister, 
Lea and others, this method by no means excludes the presence of virulent 
streptococci that are not hsemolytic in character. 

Veit contents himself with securing the lochia from the upper part 
of the vagina, using the same technic as in taking cultures from the throat 
in suspected diphtheria, while in this country it is customary to take 
cultures from the interior of the uterus, following the technic of Williams 
and using the modification of the Doderlein tube. Under the strictest 
antiseptic precautions the cervix is exposed by means of a speculum and 
fixed by a tenaculum. The tube is then passed well within the internal os, 
the lochial secretion aspirated, the tube sealed, and the contents reserved 
for examination, or sent to a laboratory. Before passing the tube, the 
vaginal portion of the cervix is carefully cleansed with sterilized cotton 
and the greatest care is taken to avoid contact with the vaginal walls or 
with the external os. 

Of course, no attempt should be made to explore the uterine interior 
if the cervix is closed and the uterus contracted. If there are ulcerated 



PUERPERAL INFECTION 701 

patches about the vulva or vagina, but with no special evidence of endo- 
metritis, all intra-uterine manipulations should be avoided. The danger 
of transmitting infection to the uterine cavity is too great. 

It should be noted, I believe, that the intra-uterine exploration i^ not 
absolutely free from the slight risk that attends all intra-uterine manipu- 
lations, and especially if practised by those unfamiliar with surgical technic, 
careless as to asepsis, or unfamiliar with the contra-indications to such 
manipulations. Franz found that in a large proportion of cases the pro- 
cedure was followed by a rise of temperature, this being especially notice- 
able in the cases in which the streptococcus was present. Although his 
examinations were conducted with the most scrupulous care, he was led to 
discontinue them out of regard for the interests of his patients. Thomen 
also noted the occurrence of a chill and fever after bacteriological 
examination. 

The method of \'eit is not as reliable or accurate as that of Williams, 
but it is much easier, and somewhat safer, for general use. However 
uncertain it may be in some respects, it often gives useful information by 
revealing the presence of the gonococcus. 

Much has been expected of blood examination, but thus far little has 
been realized. In acute cases, and in the last stages of pysemic infection, 
the streptococci are found in large numbers. Many cases recover, however, 
when only scattered colonies are found in the blood. 

The presence of streptococci in large numbers, then, is a bad prognostic 
sign, but in these cases the general symptoms alone are sufficient to show 
that the patient is in a very grave condition. Furthermore, as Williams 
has pointed out, many cases die without the presence of the streptococci in 
the blood and many recover when scattered colonies are found. 

In this connection it should not be forgotten that the development of 
a leucocytosis during, and shortly after, labor and again at the time of the 
establishment of the milk secretion is a physiological phenomenon, and 
therefore not an evidence of infection. 

Having excluded other causes of fever and thus reached the conclusion 
that the case before us is one of infection, we have to decide the important 
question. What is the type of infection? The ability to do this depends 
upon a knowledge of the varied clinical history of infection, which I advise 
every reader to study carefully, and upon the results of bacteriological 
examination, which, though as yet by no means infallible, renders valuable 
service in establishing or confirming the diagnosis in suitable cases, and 
especially in making the diagnosis of gonorrhoea. 

Since, however, bacteriological examination is not infallible, and very 
often not available, it is highly important that the physician become familiar 
with the clinical history of puerperal infection, \\dien this has been 
accomplished he will usually be able to diagnose the type of infection, if 
only by exclusion, though a few days may be required to clear up the 
matter. For example, if in a given case the pulse is slow and the general 



702 PATHOLOGY OF THE PUERPERIUAI 

condition good, the severe forms may safely be excluded. If there is no 
odor to the lochia the case is not one of saprsemia. Peri- and parametritis 
may be excluded at once by the absence of the physical signs. There have 
been no chills, or at best only a slight chill, or rigors at the beginning, 
therefore py?emic infection is not probable. The symptoms began about 
the fourth day after deliver)^ which is rather late for most types of viru- 
lent infection, but early for pyaemia, etc. The case is probably one of mild 
streptococcic endometritis. 

Or again, there is fever toward the end of the first, or at the beginning 
of the second, week, too late for most types of infection. Pyaemia, which 
usually begins at this time, is rendered improbable by the fact that the 
temperature is continuously high and without remissions or chills, though 
there may have been a chill at the beginning. In femoral phlebitis, which 
is often first noticed at about this time, there is pain in the thigh and 
oedema of the leg. There is another condition, however, which frequently 
causes a rise of temperature a week or two after delivery, namely mastitis. 
This leads the examiner to palpate the breasts. A point is found at which 
firm pressure elicits tenderness, though the patient had complained of no 
special pain. The case may be one of deep-seated suppuration of the breast. 

The history of labor often aids in the diagnosis, e.g., a cervical tear 
reminds one of the likelihood of the early development of a pelvic cellu- 
litis. Conditions which necessitate manipulations about the placental site, 
e.g., placenta prsevia, or adherent placenta, are more apt to be followed 
by pyaemia. This is also true of infection occurring during labor, intra- 
partum infection, while the placental sinuses are still open, as in premature 
rupture of the membranes. Retention of the membranes is a common 
cause of sapraemia, etc. Pallor, dyspnoea, rapid pulse, 120 or more, a pro- 
longed and severe chill or repeated chills, sleeplessness, jaundice, these are 
all indicative of severe infection. 

Prognosis. — The prognosis depends, of course, upon the variety of 
infection and, since the most virulent forms are now comparatively rare, 
the question of a fatal issue is not common, at least in the practice of those 
who use modern methods. The question has become one of morbidity 
rather than mortality. It is usually estimated that in maternity hospitals 
the mortality is less than i per cent. In private practice it is probably 
higher, although exact figures are not attainable. This is by no means 
necessarily the fault of the practitioner as is too often assumed. In general 
practice there are often circumstances militating against success which are 
quite beyond the control of the attendant. Chief among these is the lack 
of competent assistance. We all know how difficult it is to keep one's 
hands or gloves immaculate during the whole course of an operation in 
which the operator must supervise the anaesthesia and attend to various 
other matters ; and how often the vulvar dressings must be left to those 
who know, or care, little for the rules of asepsis. 

In studying the prognosis of this affection, nothing has so forced itself 



PUERPERAL INFECTION 703 

upon my attention as that the pulse is the best index of prognosis. As a 
rule, the mere elevation of temperature to 103, or even 104 degrees, without 
a corresponding rapidity of the pulse, let us say with a pulse of not more 
than 112 to 116 degrees, does not indicate serious or immediate danger. 
Such a case is probably one of sapr^emia, or if it be a septicaemia it is of 
the mild type. Of course such a rule is subject to exceptions, but in a 
fairly large experience it has served me well. On the other hand, a rapid 
pulse is characteristic of the severe types of infection. If it be 120 or 
more, and particularly if it remain steadily at this height for from 24 to 36 
hours or more, I feel that there is cause for anxiety even though the tem- 
perature be not high. Indeed, a comparatively low temperature with a 
high pulse-rate is a notoriously unfavorable combination. This rule, too, 
has its exceptions. A congenitally rapid pulse may excite undue anxiety, 
or its rapidity may be the result of pain, apprehension or nervous anxiety. 
Now and then it may mean a beginning pelvic peritonitis which happily 
becomes localized and does not go on to become a general peritonitis. 

Here let me note that the localization of the septic process at the side 
of the uterus, as shown by pain and tenderness in that locality, is in cases 
apparently severe a favorable symptom, at least so far as any immediate 
danger to life is concerned. It may mean long disability, but it is nature's 
method of preventing the free admission of the bacteria to the general 
peritoneum with consequences rapidly fatal. 

Cases of grave infection, general peritonitis, acute sepsis, virulent 
streptococcic endometritis, are characterized by marked pallor and per- 
sistent sleeplessness, both bad symptoms. Dyspnoea is also a bad symptom, 
whether caused by mechanical obstruction, as in peritonitis, or by the 
destruction of the red corpuscles, as in profound septicaemia. 

Slight chills or rigors are not necessarily of any great significance. A 
prolonged and severe chill may usher in a general peritonitis or a severe 
infection. Repeated chills are of bad omen, as indicating renewed 
infection, especially pyaemic infection. 

The presence of haemolytic streptococci in the lochia is indicative of 
serious infection, but the organisms are often found in patients who do 
not seem very ill. The presence of bacteria in large amount in the blood 
is a fatal prognostic, but in such a case the clinical symptoms are usually 
too plain to be misunderstood. On the whole the microscope confirms, 
rather than establishes, a bad prognosis. 

Treatment. — The treatment of puerperal infection is preventive and 
curative. As is so often the case in obstetrics, the preventive treatment 
is by far the most important. Infection is comparatively easy to prevent, 
but in its severer forms it is very difficult to cure. 

The preventive treatment has been sufficiently discussed in connection 
with the management of normal labor and it is unnecessary to go over the 
subject again here. I may be permitted, however, to repeat what I 
consider the most important points. 



704 PATHOLOGY OF THE PUERPERIUM 

1. Gross or macroscopical cleanliness, i.e., prolonged, thorough and 
repeated washing of the hands with soap and water (running water when 
it can be obtained) before the use of chemical disinfecting solutions. 

2. Use rubber gloves in making examinations, and dip the hands into 
lysol solution before introducing the fingers, because lysol is a lubricant 
and lubrication lessens the traumatism and abrading of the maternal 
tissues. Avoid vaseline and all unguents, whether from jars or collapsible 
tubes, and whether said to be sterile or not. 

3. Strictly limit the number of internal examinations. Learn to 
observe the progress of labor by external examination, and by observ^ation 
of the patient. 

4. No douches before, during, or after labor, except for hemorrhage. 

5. No unnecessary operating and, above all, no unnecessary operating 
before complete dilatation of the cervix. 

6. No examinations or manipulations during the third stage, unless 
absolutely necessary. 

7. Avoid perineal and cervical tears by the methods already described. 
Repair all perineal tears that involve more than the fourchette. 

8. Examine the placenta and membranes carefully in every case. 

The treatment of puerperal infection continues to be a matter of 
controversy. In the days of our fathers it was, like most other disorders, 
treated by calomel and the lancet. Later it became the field of radical 
surgical gynaecology, the domain of the curette and the knife. On the 
whole, it may well be doubted whether this was an improvement upon 
previous methods. 

With accumulating experience and a better understanding of the 
pathology of the condition it has come to be well understood that much 
of the former treatment of puerperal infection, surgical as well as medical, 
was not only unnecessary but injurious. 

The present tendency, and one with which I cordially sympathize, is to 
recognize that the majority of the cases of puerperal infection are self- 
limited and have a natural tendency to recovery, that surgical operations 
and intra-uterine manipulations are seldom indicated, as a rule do more 
harm than good, and are to be undertaken only upon clear and definite 
indications. 

It is evident, too, that in spite of the opposition of the ultra-conservative 
the serum treatment is gradually gaining recognition as a safe and not 
infrequently beneficial method of treatment, and that here, as in other 
varieties of infection not amenable to local treatment, serum or vaccine 
therapy afl:'ords our chief hope of success. 

Many writers advise that a careful bimanual examination be made as 
a preliminary measure, in order to determine the position and condition 
of the pelvic contents. As a matter of fact, there is no great haste about 
such an examination. Such an examination, especially if made by a man 
who prides himself upon being very thorough and radical, may do a great 



PUERPERAL INFECTION 705 

deal of harm by reopening partly healed tears, tearing open freshly formed 
adhesions, or even rupturing a pus cavity. It is especially dangerous in 
cases of gonorrhoea! infection. The height of the fundus and progress 
or arrest of involution, as well as any external tenderness, are determined 
by cautious palpation, and a finger in the vagina takes note of the condition 
of the cervix and of any sensitiveness or increased resistance in the 
cul dc sac. 

I\Iake no unnecessary examinations in cases of infection, and if exam- 
ination becomes necessar}^, proceed with all caution and gentleness. 

Another piece of advice often given, especially by those whose training 
has been chiefly surgical or gynaecological and who have seen but little 
of pure obstetrics, is to proceed at once to a complete disinfection of thg 
birth canal. This advice is based upon two false assumptions, first, that 
the birth canal can be disinfected by any of the means at our disposal, 
which, except in certain cases of sapraemia, is far from the truth; and 
second, that puerperal infection is an entity that can be washed out or 
scraped out of the uterus, which is also erroneous. 

Instead of the above I personally advise that the birth canal, and 
especially the interior of the uterus, be let severely alone, unless there is 
some good reason for interference. To^ this rule I recognize but three 
exceptions : severe hemorrhage, retention of lochia, and retention of the 
placenta. 

The first two of these emergencies are quite rare and are discussed in 
their appropriate places. The third, retention of the placenta, hardly ever 
occurs in the practice of competent men. 

If there is a history or a strong suspicion of placental retention, con- 
firmed by a gaping os and foul discharge, the finger should be introduced 
into the uterine cavity and the placental tissue removed. It is better to be 
satisfied with the removal of the bulk. Scraping the placental site and 
the cornua with the curette, as often advised, is not only unnecessary but 
dangerous. A single intra-uterine douche of hot salt solution, or one-half 
per cent, lysol, suffices to remove any fragments that remain, to secure good 
uterine contraction, and perhaps to remove any organisms that have been 
introduced by the manipulations. It is seldom, if ever, necessary to repeat 
this douche. 

This is accomplished by putting the patient in the lithotomy position at 
the edge of the bed or table and bringing the cervix to the vulva by pressure 
upon the fundus. In these cases the cervix is patulous and the introduction 
of the finger easy. Strict asepsis must be observed. If the patient is 
sensitive a few whififs of ether may be necessary. 

This procedure is practically never necessary if a competent physician 
has examined the placenta after delivery and found it entire, and as a 
matter of fact I now seldom resort to it. To explore the uterine cavitv in 
every case on the theory that a small piece of placenta or membrane might 
possibly have been left behind is to my mind a dangerous folly and does 
45 



706 PATHOLOGY OF THE PUERPERIUM 

far more harm than good. If the uterus is well contracted and the cervix 
closed it is certain that interference is contra-indicated. 

With the single exception noted above I avoid intra-uterine douching. 
There is no logical reason to suppose that it does any good and there is 
no doubt that it occasionally does harm. 

Especially to be deprecated is the employment of bichloride or carbolic 
solutions. These solutions do not penetrate animal tissues, as Bumm has 
shown experimentally. It is, therefore, evident that their action can at 
best be only superficial. Many cases of sudden death from embolism are 
on record. The necessary manipulations are highly undesirable, and, most 
important of all, such injections have been followed by fatal poisoning. 
Nor is this to be wondered at when one recalls the quantities used, and 
the extent of raw and bleeding surface exposed. In many cases the first 
symptom is twitching of the face, and these cases, like those of delayed 
chloroform poisoning, have not infrequently been mistaken for toxaemia 
or eclampsia. If some chemical disinfectant must be employed, 50 per cent, 
alcohol is perhaps the best, and is at all events harmless. 

While I have practically discarded intra-uterine douches, I believe that 
vaginal douching, with proper precautions, is quite harmless, and to a 
certain extent beneficial. It aids in the removal of decomposing lochia 
which has a tendency to collect in a stagnant pool in the posterior ctd de sac, 
and in my experience is very refreshing and comforting to the patient. 
They are to be employed, however, only by a trained nurse in whom the 
physician has entire confidence. She should be instructed to practise the 
most rigorous asepsis, and to insert the tube well within the vaginal orifice 
but no farther. To push the tube too high is to risk carrying infective 
material into the uterus. 

The vaginal douche is perhaps a luxury rather than a necessity. Its 
administration should never be entrusted to an untrained nurse, as is so 
often done. Its use in hospital wards, where one nurse has charge of 
several patients, is of doubtful advisability. 

If we have no means of surely and safely disinfecting the uterus, we 
can at least attempt to aid nature in securing good uterine contraction. 
This is attained by the application of an ice-bag over the symphysis and 
the administration of ergot. One drachm of the fluidextract may be 
given at once and followed by twenty minims three or four times a day, 
thus maintaining a steady and continuous contraction of the uterus. An 
infected uterus is usually a flabby uterus. The securing of good con- 
traction is the most effectual method of securing the expulsion of all kinds 
of infected debris that may be present. It also prevents absorption of 
septic material from the vagina, and by the contraction of the muscles of 
the uterine wall prevents the transmission of infection through the uterine 
lymphatics. Most of us have learned to think of ergot as useful only 
in the prevention and arrest of hemorrhage and have forgotten that it has 
other and important uses. 



PUERPERAL INEECTION 707 

The ice-bag also aids in securing uterine contraction and in diminishing 
pain and soreness when present. Perhaps it has some effect, too, in inhibit- 
ing bacterial development. This has been denied by experimenters, but we 
know that by its use a threatened abscess of the breast can often be aborted. 

The curette is mentioned only to be condemned. To my mind it would 
be just as sensible to curette a diphtheritic throat as a uterus lined with a 
streptococcic membrane. jMultiplied experience confirms this belief. The 
practice has been given up, or very much modified, by nearly all the 
teachers and writers who strongly advocated it ten or fifteen years ago. 
This is of itself convincing testimony. My own experience leads me to 
believe that in many cases death has been the direct result of the diligent 
scraping of the uterine interior by some very strong believer in the 
" surgical method." 

We need not then hope to scrape out or wash out the infective process. 
As ^^llliams pertinently remarks, the organisms have penetrated far into 
the uterine wall long before the initial chill or the first rise of temperature. 
Beneath the necrotic layer of endometrium that soon forms are arrayed 
the leucocytes, nature's barrier against infection. Sometimes the organ- 
isms are so virulent that nature's defences are useless, but in general they 
serv-e their purpose well, and it is the height of folly to interfere with them. 

If the infection has taken the form of a simple catarrhal vaginitis and 
the uterus is apparently uninvolved, the ice-bag and ergot are still useful, 
since the best way to keep the infection out of the uterus is to keep the 
latter well contracted. Vaginal douches are indicated with the same 
proviso as above. 

Something may be done by posture to favor drainage. In actual or 
threatened peritonitis the head may be elevated, as in the Fowler position. 
Some advise the Eowler position in all cases, but this is a mistake. There 
is no reason to suppose that it favors drainage from the uterus. Elevating 
the head does not diminish, but rather increases, the normal anteversion 
of the puerperal uterus. Moreover, it increases the work which the heart 
has to do. 

As a rule, it is better to caution the patient against spending too much 
time in the dorsal position and to advise her to spend more time in the 
lateral position, turning first upon one side and then upon the other. The 
lateral position greatly favors drainage from the vagina and uterus. If one 
gives a vaginal douche when the patient is in the dorsal position, the 
solution remains in the vagina, but if she turns upon the side it runs out. 
Here, as elsewhere, water does not readily flow up hill. 

Ulcerated surfaces about the perineum and vagina should be cauterized 
with a 20 per cent, solution of silver nitrate, or with tincture of iodine. 
In these cases all intra-uterine manipulations, and even vaginal douches,, 
should be most scrupulously avoided, lest infection be carried from a 
situation where it Is comparatively harmless into the uterus where it is 
highly dangerous. 



708 PATHOLOGY OF THE PUERPERIU^I 

\Mien the infection has traversed the uterine wall and become localized 
in the cellular tissue at the side of the uterus, or in the pelvic peritoneum, 
it is perfectly plain that intra-uterine therapy can do no good, though 
vaginal douches may still be used. An ice-bag over the aitected side serves 
to alleviate the sulTering and perhaps to limit the spread of the infectious 
process, and a hypodermic of morphine may help to bridge over the most 
tr}-ing period and perhaps, by limiting peristaltic movement, to diminish 
inflammation. Then, too, severe pain is very depressing and exhausting 
to a recently delivered woman. This treatment, together with prolonged 
rest in bed and attention to the bowels, preferably by copious enemata of 
olive oil, usually ser\-es to abort abscess formation, especially in cellulitis, 
by far the most common of the localized infections. Even if suppuration 
is suspected, it is better to postpone the incision until fluctuation is unmis- 
takable. ^Mien suppuration appears inevitable, hot applications should be 
substituted for the ice-bag. It may be necessar}- to open the abscess above 
Poupart's ligament, but more commonly it " points " in the ciil de sac of 
Douglas and must be opened through the vagina. A word of caution here. 
It is the most natural thing in the world for the inexperienced operator to 
make a free incision in the most prominent part of the swelling in the 
vaginal vault. This has resulted in severe and even fatal hemorrhage 
Trom the uterine arter}-. The incision should begin close to the side of the 
cervix, even though the latter be pushed far to one side. This incision 
radiates outward and backward, and should be long enough to admit the 
finger. The abscess is then sought by the finger or by blunt dissection. 
AMien found, it is opened by a pair of blunt-pointed dressing forceps, the 
blades of which are separated and withdrawn in that position. A gauze 
drain is inserted, ^^'ashing out the cavity is unnecessar\- and unwise, since 
there is always the possibility of washing the pus upward where it may 
do harm. 

Pus tubes and abscess of the ovary must usually be operated upon 
eventually, but the operation should be delayed as long as possible since, 
as noted by many writers, the streptococci may remain virulent for a long 
time and the operation for their removal may give rise to a general 
peritonitis. Fortunately these abscesses are not ver\' common. 

The general treatment of puerperal infection does not diflr'er in principle 
from that of infection in general, and is best considered under four heads, 
as follows : 

1. Specific antidotal treatment. 

2. General supporting measures. 

3. Symptomatic treatment. 

4. Operative treatment. 

There is no drug that has shown itself a specific in puerperal infection, 
but we have in the antistreptococcic serum, first introduced bv ]\Iarmorek. 
an antidote which is in certain classes of cases of o-reat value. 



te' 



PUERPERAL INFECTION 709 

In my opinion premature and ill-advised reports have so prejudiced 
the profession against the serum that much harm has resulted. These 
reports have been based upon false ideas of what the serum should be 
expected to accomplish, and of the time and method of its administration. 
Given in insufficient doses, as a last resort in cases that have perhaps been 
subjected to curettage and other improper treatment, little can be expected 
of this or any other treatment. 

The serum is not an antitoxin and does not produce the rapid, positive 
and brilliant results that so often attend the administration of the diph- 
theria antitoxin. Its action, as has recently been clearly shown, is to 
stimulate phagocytosis, and thus aid the natural forces in their conflict 
against the invading bacteria. It has been demonstrated, and upon this 
point all agree, that it is practically harmless. 

From these facts it follows that, in order to secure a fair test of this 
agent, it should be administered early and often. I do not agree, however, 
with those who claim that it should not be given late in the disease, 
since I have seen good results from its liberal use, even under these 
circumstances. 

Bumm, who has made extensive observations with the serum, while 
admitting that the serum is ineflectual when pus formation has occurred, 
as in general peritonitis, abscesses in the parametrium and pysemia, states 
positively that in cases of streptococcus endometritis, of septicccmia without 
localization, and of pJiIcguiasia alba dolens, brilliant and positive results 
are often secured by the injection of large doses of the serum — not less 
than 50 to 100 c.c. He states that the only by-effects that he has noticed 
are erythematous eruptions, and joint inflammations, which, accompanied 
by fever, appear from 5 to 8 days after the injection, and spontaneously 
disappear. 

]\Iy own results with the serum in severe streptococcic endometritis 
and in severe sepsis without localization have been very encouraging, and 
I strongly advise its employment. The objection has frequently been 
made that many cases of infection are due to the staphylococcus, the colon 
bacillus, and various other organisms than the streptococcus. This, of 
course, is true, but while such cases constitute in the aggregate a large 
number, nevertheless the large majority of infections are of streptococcic 
origin. Hence, I am accustomed to give the patient the benefit of the 
doubt if the bacteriological diagnosis is insuflicient or unavailable. 

It is a very significant fact that some of those who formerly opposed 
the use of the serum have, after further trial, become converted to its use. 
Among these is Hirst, who, after giving up the use of the serum, has now 
resumed its use because, as he says, it cannot be denied that it " is followed 
occasionally by decided, and sometimes by brilliant, results." Hirst injects 
20 to 80 c.c. one to four times a day. Marx, before his lamented death, 
gave similar testimony. 

Of course, a good preparation is essential. I have used for the most 



710 PATHOLOGY OF THE PUERPERIUM 

part, and with great satisfaction, that manufactured by the New York 
City Board of Health. 

Up to the present time the resuUs of vaccine therapy seem to have been 
less encouraging- than those obtained with the serum. Williams quotes 
Sir Almroth Wright as expressing the opinion that nothing will be accom- 
plished in streptococcus infection, although there may be in the case of 
infection by staphylococcus or gonococcus. This probably expresses the 
opinion of most authorities at the present time. 

Salt Solution. — This apparently does good in puerperal as in other 
infections. Perhaps the amount of benefit derived is somewhat exag- 
gerated, but at all events the procedure is harmless and it is wise to give 
the patient the benefit of whatever doubt there may be. The solution may 
be injected under the skin (a pint two or three times a day), or it may 
be given in the form of the Murphy drip. The latter is least troublesome 
for the patient. In bad cases the intravenous method is to be preferred 
as more direct and certain in its action. 

While there is no drug which is a specific for infection, it is a foolish 
fanaticism to do away with drugs altogether. Aconite, veratrum and 
other depressing drugs have been discarded, and wisely, and attention is 
now directed chiefly to the relief of pain and when necessary to stimulation 
and support. Anodynes are to be used with discretion, of course, but when 
really indicated should not be withheld. 

I do not give alcohol in mild cases, or when the pulse is good, unless 
the patient is habituated to its use. In that case I usually allow her about 
what she has been accustomed to have. Its antidotal effect, in certain cases 
of profound toxaemia and great prostration, is observed in severe strepto- 
coccic endometritis and in general sepsis. When, with profound septic 
intoxication, we find a coated tongue, rapid and feeble pulse, and perhaps 
ataxia suhsultiis and delirium, the effect is sometimes remarkable. Its 
effect here seems like that observed in bad cases of typhoid. Its antidotal 
effect is clearly shown by the fact that patients unaccustomed to its use 
can take enormous doses without any obvious ill effects. How it acts has 
been a matter of dispute, but since it has been shown that alcohol is a food 
up to the point of oxidation, it seems probable that it replaces the waste 
caused by prolonged high temperature. The dose is to be regulated by the 
effect, rather than by the measuring glass. 

Strychnine in conjunction with alcohol is advised by many writers, 
and is without doubt useful in bridging over emergencies, but my experi- 
ence leads me to believe that, when the pulse is rapid and weak, digitalis is 
on the whole more beneficial. I prefer to use it in the form of Digalen. 
Digitalis is more than a mere stimulant. By prolonging the cardiac dias- 
tole, during which the heart receives its blood supply, it contributes to the 
nourishment of the heart muscle, and thus aids it most materially. I have 
no fear of this drug and have often used it with beneficial results. 

Operative Treatment. — It is quite natural that the operative treatment 



PUERPERAL INFECTION 711 

of puerperal infection should have engaged the attention of the profession. 
Unfortunately the results have not been commensurate with the efiforts 
expended. There is an almost irresistible tendency with men of a certain 
type of mind to interfere actively in every case of severe infection, and tO' 
make the activity of the interference proportionate to the gravity of the 
disease. All this would, of course, be commendable, if we knew that such 
interference would do good, or even if we were sure that it would do no 
harm. This, however, is by no means the case, and one is probably well 
within the limits of truth in saying that operative interference has, on the 
whole, done more harm than good. 

^Moreover, it is well to remember that in any case of severe infection, 
any operation which involves surgical anaesthesia, some appreciable loss of 
blood, and perhaps the opening of the peritoneal cavity, if it does no good 
certainly does harm, and may turn the scale. 

Every obstetrician of large experience has seen cases of streptococcic 
endometritis, of pyaemia, and of general sepsis, without localization, recover 
from a condition apparently most desperate, and has learned that the mild 
and moderately severe types of infection have a strong tendency to recover 
if judiciously let alone. 

Of the bad effects of curettage we have already spoken. 

All this, of course, does not mean that operative measures are never 
indicated in the course of puerperal infection ; but it does mean that for 
every operation performed upon a lying-in patient there should be a clear 
and definite indication. 

The most common indication of this kind is to be found in localized 
collections of pus, e.g., those already described in connection with 
perimetritis. 



CHAPTER XXXIII 
AFFECTIONS OF THE BREASTS AND NIPPLES 

Leaving aside for the moment infection of the generative tract, which, 
at all events, in its severe forms is now uncommon in the practice of 
careful men, it is safe to say that affections of the breasts and nipples and 
their preventive and curative treatment constitute the most important 
problem connected with the management of the puerperal state. The 
results of mismanagement in this direction are far more serious than is 
commonly supposed, involving a distinct increase in fetal mortality, not to 
speak of maternal disability and suffering. Like most obstetric compli- 
cations, affections of the breasts and nipples are more easily prevented than 
cured. They are far more frequent than they should be and it cannot be 
too strongly emphasized that the probability of their occurrence and the 
necessity of taking measures for their prevention should be borne in mind 
from the beginning. The physician will be supported and aided in his 
efforts if he can impress upon the parents the undoubted fact that sore 
nipples, abscess of the breast, etc., involve a definite infant mortality. 

EXGORGEMEXT OF THE BrEASTS 

This is a simple exaggeration of the distention which occurs normally 
with the establishment of the milk secretion, on the third or fourth day. 
The breasts are very tense and hard, and there may be extreme tenderness 
on pressure, which, however, is general, not localized, as in mastitis, or to a 
less extent in caked breast. The axillary glands are enormously enlarged 
and the general discomfort is extreme. In nervous and sensitive patients 
the reflex effect of all this upon the nervous system is shown in a moderate 
pulse and temperature rise which disappears promptly with the removal 
of the cause. 

The symptoms are due to circulatory excitement rather than simple 
distention with milk. The breasts feel warm to the touch, although the 
thermometer shows no rise in temperature. Large blue veins are seen, with 
great distinctness, coursing just beneath the skin. In some cases the whole 
breast and even the axillary region may become oedematous. The con- 
dition is often confounded with " caked breast" to be considered directly, 
but is in reality quite different. 

These symptoms, which to the uninitiated are quite alarming, usually 
disappear without treatment in a day or two, but if very distressing to the 
patient may be promptly relieved by the simple expedient of emptying the 
breasts ; not because they are due to simple distention with milk, but because 
they are due to an exaggeration of the physiological hypersemia plus this 
distention. 
712 



AFFECTIONS OF BREASTS AND NIPPLES 715 

An erosion is a mere abrasion of the surface, often hardly visible to 
the naked eye but extremely sensitive and capable of causing severe pain 
to the mother during the act of nursing. It is caused by the traumatism 
involved in nursing, together with the maceration of the epithelium due 
to the moisture of the child's mouth, and the flow of milk over the parts, 
which often continues during the intervals of nursing. 

It usually makes its appearance during the first week, and the first 
symptom is pain in the affected nipple during nursing. Many women 
complain of sensitiveness from the very beginning, and when this is 
moderate in amount and is common to both nipples it is usually of 
no great significance, subsiding in a few days. When, however, the 
patient complains that one nipple is distinctly more painful than the other, 
inspection will usually reveal an erosion. Perhaps it is so small as to be 
hardly noticeable except upon close inspection, when it will be found as a 
tiny red '' strawberry " spot exquisitely tender to pressure. The attendant 
should make it a rule always to question the patient upon this point, i.e., 
to ask her whether one nipple is particularly sensitive. I have found that 
much trouble can be saved in this way. 

The nipple should be carefully examined, if necessary with a magnify- 
ing glass. The lesion, when found, is always characteristic. The epithe- 
lium has been removed and the scarlet papillary surface beneath has a 
characteristic appearance, which has given it its popular name. This 
surface is highly sensitive and acute suffering is caused by the child's efforts 
at nursing, or even by the contact of the clothing, or of any foreign body 
with the nipple. True, there may be bleeding, but this is by no means 
always the case. Bleeding is a more constant symptom of fissure than of 
erosion. 

Treatment. — ]\Iere tenderness or sensitiveness of the nipple usually 
subsides as the nipples become accustomed to the process of nursing, but 
the process may be materially hastened by the application of a 50 per cent, 
solution of alcohol, which is not only an astringent, but an antiseptic as well. 
The child should be put to the breast at regular intervals and always in 
alternation and should not be allowed to hold the nipples in the mouth 
when not nursing. The mother should be allowed a sufficient period of rest 
at night. If tenderness is extreme the case should be treated as one of 
erosion, whether an erosion can be found or not. 

This brings us to the treatment of erosions, always an important matter. 
The tiniest lesion of the mucous membrane may prove a port of entrv^ 
for an infection which may result in mastitis with all its disastrous 
consequences. 

Erosions are not likely to heal as long as the causes which produce them 
are still operative. These causes are the maceration and traumatism 
involved in the act of nursing. 

Both of these causes are best removed by the use of the nipple shield. 
The combination glass and rubber shield of the kind shown in Fis:. 139 



716 PATHOLOGY OF THE PUERPERIUM 

is by far the best. The openings in the rubber nipple should not be too 
small, since suction is a little more difficult than in normal nursing. Some- 
times the nipple is so long as to project into the child's throat, thus render- 
ing nursing impossible. This is to be remedied by drawing the nipple 
backward farther over the neck of the bottle, or by pushing the ivory 
disk nearer the child's mouth. Again, the nipple may be too large for 
the child's mouth or the holes in the nipple are too small, and in this 
case it must be changed. A resourceful and intelligent nurse will almost 
always succeed. The method involves some trouble at first and an indolent 
or incompetent nurse wdll often attribute failure to the child, when the 
fault is her own. 

The only obstacle to this treatment is the occasional opposition of 
mothers and untrained nurses to the method, due to the fact that some 
children at first refuse to take the nipple. This can usually be overcome 
by having the mother lie so that the nipple looks downward and expressing 
a few drops of milk into the nipple by gentle massage of the breast. 
A^ery small, w^eak or premature children, it is true, may not be able to take 
the nipple. These should be fed with a medicine dropper or some similar 
contrivance, the milk meanwhile being obtained from the breasts by 
massage which is applied at regular intervals. 

The whole apparatus should be kept scrupulously clean. After each 
nursing it should be taken apart, thoroughly cleansed and immersed in a 
solution of boric acid, there to remain until again used. 

Erosions are touched with a drop or two of 8 per cent, silver nitrate 
solution. The nipple is then well powdered with a mixture of equal parts, 
by volume, of sterilized bismuth subnitrate and salicylic acid, and covered 
with sterile gauze arranged in such a way as not to press upon the nipple. 
Salves and ointments are best avoided. It is difficult to sterilize them and 
almost impossible to keep them sterile. 

Under this treatment erosions rapidly dry up and disappear. The 
method is practically that which was used at the Sloane Maternity Hospital 
during the residenceship of Tucker, and is as efTectual now as then. The 
silver solution is applied after each nursing, and the result is the formation 
of a scab under which healing takes place. The silver solution should 
be applied directly to the eroded surface under the careful guidance of the 
€ye, and not simply allowed to dissipate itself over the nipple. Repeated 
applications thicken and strengthen the scab, w^hile the use of the nipple 
shield prevents its detachment by the efforts of the child in nursing. 

Another good method is the application, with a camel's-hair brush, of 
successive thin layers of the compound tincture of benzoin, and then allow- 
ing the child to nurse by means of the shield already described. This 
method may be practised with a little instruction by any intelligent member 
of the family. A^arious astringents and antiseptic powders, tannic acid, 
aristol. etc., have been advised. 



AFFECTIONS OF BREASTS AND NIPPLES 717 

Fissures of the Nipple 

A fissure of the nipple is to be regarded as the result of gross neglect. 
It differs from an erosion in the fact that the lesion is not confined to the 
mucous membrane, but extends deeply between the papillae. The nipple 
seems to have cracked open and perhaps bleeds freely. There is no 
possibility of mistake in diagnosis. 

Treatment. — Here, again, the best application is silver nitrate. It is 
best applied in the form o-f lunar caustic. The " stick " is whittled down 
to a sharp point and applied carefully and thoroughly to the entire surface 
of the fissure, the balance of the nipple being covered meanwhile with 
sterile gauze. This serves to limit the application to the fissure proper 
and prevent its diffusion over the moist surface of the entire nipple, thus 
turning the nipple black, a disfigurement which is not pleasing to the patient. 

Fissures of the Base 
Now and then, fortunately not very often, the fissure is at the base 
of the nipple, i.e., at its junction with the areola. The nipple looks as 
though it were being separated from the breast. These fissures are most 
intractable of all, since every movement of suction tends to reopen the 
wound. In bad cases it may be necessary to stop nursing. Even these 
cases, however, may usually be cured by the methods above described, if 
begun early. Before giving up the attempt it may be wise to try the 
experiment of removing the child from the breast for a few days, feeding 
it in the meantime with milk expressed at regular intervals by massage. 

Puerperal Mastitis or Abscess of the Breast 

One of the greatest misfortunes that can befall the puerperal woman 
is the development of inflammation of the breast proper. While seldom 
fatal it not only prevents nursing, but, if at all extensive, destroys the 
functional activity of the breast and thus prevents nursing in future preg- 
nancies. In this way it undoubtedly tends to increase infant mortality. 
Moreover, it is a painful and exhausting process, necessitating one or more 
operative procedures and leaving more or less mutilation, too often a per- 
manent reminder of carelessness or defective technic. The subject is one 
which deserves more attention than it usually receives (Fig. 418). 

Etiology. — Alastitis is due to infection through lesions of the nipple. 
The reader should grasp this fact at the outset and never let it go. Its 
recognition is of the greatest possible importance from the stand-point of 
prevention. It is true that certain writers maintain that bacteria may pass 
directly into the milk ducts of a sound and uninjured nipple, and thus give 
rise to a parenchymatous mastitis, and that a breast abscess may be part of 
a general pyaemia, but such cases, while of course theoretically possible, are 
so rare as to be of no practical importance. Personally, I have never seen 
a case of abscess occurring during the lying-in period in which I could 
not detect or elicit a history of erosion or fissure of the nipple. 



718 

Irregularity in nursing, inspissation of milk, and engorgement of the 
breasts are usually regarded as predisposing causes. I do not think their 
influence is very great. 

Classification. — Leaving aside the small, superficial abscesses or 
'' boils " which are occasionally found just beneath the skin, usually near 
the areola, and which are of no great clinical importance, inflammation of 



Infected lobules of ^., 
deep glands"" 



(Retro mastitis) Extension of ^, 
infection into retro mammary <l!^ 
connective tissue *"• 




Spread of infection in connective tissue 
(mterstitial suppurative mastitis) 



Fissure 



Excoriations 



Infected milk ducts 



:?-Infected acini 



Infected gland lobules (parenchy- 
- /^■-'^matous suppurative mastitis) 



Pig. 418. — Extension of infectious processes in the breast. 

the breast is divided into two principal classes, parenchymatous and 
interstitial (phlegmonous). In the first, the offending organism is usually 
staphylococcus albus, and the infection is transmitted through the milk 
ducts. In the second, the organism is the streptococcus, and infection is 
transmitted by means of the lymphatics. 

Clinical History. — In the parenchymatous form, which is more com- 
mon, the first symptoms are a rise of temperature and an increase in the 



AFFECTIONS OF BREASTS AND NIPPLES 719 

pulse-rate. Fever and rapid pulse are noted before the local symptoms 
are marked ; indeed, in some cases while they are still hardly noticeable. 
In these cases the local symptoms are often entirely overlooked until the 
process has gone too far for any hope of arrest. The area of tenderness 
is not always well-marked at first, and perhaps the indurated area is deeply 
located and not easily made out. The area of induration and tenderness 
is at first ill-defined, and can be located only by deep pressure, and the 
cause of the fever may be for a day or two undiscovered. Hence the rule : 
" In every case of fever occurring during the lying-in period examine the 
breasts." The process may take rise in any part of the breast, but as a 
rule it is the lower and outer part, i.e., the most dependent part, that is 
aft'ected. 

The Submammary Form. — In this form, fortunately rare, there is an 
extension of the infectious process, a parenchymatous mastitis, to the 
submammary space instead of to the surface of the gland. The general 
symptoms are threatening, but the local symptoms not well-marked. Late 
symptoms are oedema and swelling at the periphery of the breast. At this 
time the breast appears to be lifted above the chest wall and on palpation 
feels as though it were floating upon something beneath. If no relief is 
afforded the condition may go on to one of grave general sepsis with all 
its symptoms and dangers. 

Interstitial or Phlegmonous Mastitis. — In this form the symptoms are 
more acute. Swelling and tenderness appear at an early period and 
progress is rapid. The surface of the breast soon takes on an erysipela- 
tous appearance. Measures designed to abort the process have less 
effect. 

Diagnosis. — It is usually taken for granted that the diagnosis of mas- 
titis can present no difficulty — that its existence or non-existence must be 
self-evident. And yet mistakes are often made, though most of them, it 
is true, are due to carelessness. The chief cause of this is the latency 
of the symptoms already mentioned. This is often marked in the parenchy- 
matous, but most of all in the submucous forms. In the latter variety 
even the careful and experienced examiner may be obliged to reserve his 
decision. Every obstetric consultant occasionally sees a case in which an 
unexpected mastitis has been treated as one of pelvic infection. 

It is most important to distinguish between " caked breast " and true 
mastitis, especially the parenchymatous form. In either case there is a 
mass in the breast which is moderately tender, and even in caked breast 
there may be more or less fever from one cause or another. Rigors, and 
especially distinct chill, of course, indicate infection. A temperature of 
loi to I02, lasting for forty-eight hours, usually means infection. Most 
significant of all is a pulse of 120, continuing for from thirty-six to forty- 
eight hours. And yet I have noted occasional exceptions to these rules,, 
especially in the case of neurotic individuals. 

Rigors, and, above all, a well-marked chill, point to mastitis. In the 



720 PATHOLOGY OF THE PUERPERIU.M 

case of a doubtful swelling the aspirating needle may solve the difficulty. 
The coexistence of an erosion or fissure of the nipple of the same breast 
makes the diagnosis almost positive. 

All doubtful cases should be treated as cases of mastitis. H* a mxistake 
has been made such treatment, pursued for a day or two. can do no harm, 
while to treat a beginning mastitis by hot applications and massage is to 
favor its rapid dissemination throughout the gland. 

Treatment. — ^lost important of all is prophylaxis. This has already 
been considered, and it remains only to repeat and emphasize what has 
been said. Every case should be approached with this fact in mind. 
Erosions of the nipple can and should be quickly cured, fissures should be 
prevented and regularity and cleanliness in nursing strictly enjoined. 
Physicians and students should be constantly reminded of their duty in 
this matter. I have often noticed that many. Avho are commendably careful 
as to the technic of vaginal examinations and obstetric operations, are 
strangely ignorant or indifferent with reference to the prophylaxis of 
breast infection. This fact should, I think, be emphasized by teachers 
of obstetrics. 

As regards preparation during pregnancy, I do not believe that for 
the normal nipple anything more is necessary than cleanliness and the 
avoidance of injurious pressure. AMien we see that those who attempt 
to harden the nipples with alcohol claim results as good as those who 
attempt to soften them with oils and ointments, we may well believe that 
nature is better at this kind of preparation than art. If the patient insists 
upon something, a 50 per cent, alcohol solution, which is a good antiseptic, 
is. perhaps, as good as anything. 

Suppose that symptoms of mastitis are present but not vers- marked. 
Shall the child be removed from the breast? ^^lost authorities advise that 
this be done on the ground that by stopping nursing we diminish the 
functional activity of the gland. It has always seemed to me that this some- 
what theoretical objection is more than counterbalanced by the fact that 
the cessation of nursing causes engorgement of the breasts and inspissation 
of milk. This was also the conclusion of Tucker after an enormous experi- 
ence at the Sloane ^laternity Hospital. If evidences of suppuration are 
positive, the child is, of course, at once removed from the breast. 

The application of cold is very valuable. An ice-bag should be applied 
over the tender area and kept there constantly. This not only aids in 
aborting the process, but materially diminishes the suffering of the patient. 
The best local application is ichthyol ointment 50 per cent., or even pure 
ichthyol, which should be covered with oiled silk or rubber tissue in order 
that it may be absorbed by the underlying tissues and not by the dressings. 
Over the ichthyol and the rubber tissue may be placed the ice-bag. All 
unnecessar}^ handling of the parts should be scrupulously avoided. The 
suction apparatus of Bier for the production of local hyper^emia has been 
tried, but the results have not been encouraging, and it seems plain that 



AFFECTIONS OF BREASTS AND NIPPLES 721 

treatment of this kind, if it does not do good in incipient mastitis, can only 
do harm. Rather free purgation by saHnes helps materially. Above all 
things, do not make a mistaken diagnosis of " caked breast " and use 
massage and hot stupes. 

This simple treatment, begun early and carried out rigidly, will abort 
many cases. But what of those which cannot be aborted, or which are 
seen too late ? 

As soon as fluctuation can be detected, the abscess should be opened 
by an incision radiating from the nipple, as shown in Fig. 419. The manner 
of making this incision is important. It should be carried down through 
the skin and subcutaneous fat, but only as far as the breast proper. To 
continue the incision with the knife 
is to risk cutting the ducts and 
causing a milk fistula which may be 
long in healing. A pair of artery |^ . 

clamps or some blunt instrument is 
now pushed into the abscess cavity 
and the opening bluntly enlarged, 
until it freely admits the finger, 
which explores the cavity, and, if 
necessary-, converts two or three 
pockets into one. The cavity is 
then lightly packed and one or 
more counter-openings made if 
necessary. It is better to make 
these counter-openings through the 
post-mammary space than through 
the breast itself, thus avoiding fur- 
ther destruction of the gland tissue. 

The cavity should not be too 

tightly packed, nor should the Fig. 4i9.-Treatment of mammary abscess. Good 

packing be continued too long. direction of mcision. 

There are some cases in which the cavity does not close because its closure 

is made impossible by the treatment adopted. 

A suction apparatus for removing the collected pus when the wound is 
dressed is very useful. The use of such an instrument does away with 
the temptation to squeeze the breast and thus spread infection throughout 
the gland. 

In the submammary form the incision is made at that point in the 
breast which appears to be most dependent as the patient lies upon her 
back. The use of the aspirating needle may be necessary. 

In making an incision in the breast, the operator should be careful to 
keep entirely outside the pigmented area. If he does not obser\^e this pre- 
caution, the pigment follows the line of incision and may involve a large 
portion of the breast, causing disfigurement not at all pleasing to patient. 
46 




722 PATHOLOGY OF THE PUERPERIUM 

Deficient Secretion of Milk (Agalactia) 

This is quite common. In many cases the cause defies discovery. 
Strong and healthy women may be unable to nurse their children, while 
anaemic and seemingly delicate women may have an abundance of good 
milk. Now and then the cause of the patient's inability to nurse may be 
found in the presence of some exhausting disease, e.g., tuberculosis, car- 
cinoma, etc., or in the acute anaemia following a severe hemorrhage. Some- 
times the cause may be a local condition, e.g., the destruction of the 
parenchyma of the breast by a mastitis following a former labor. Late 
primiparity is an undoubted factor, and there is such a condition as 
hereditary glandular deficiency. 

Treatment. — In the first place the attendant should not admit too early 
that the supply is deficient. I have waited until the fifth or sixth day. In 
some families the theory that the mother will not be able to nurse her child 
is only too eagerly accepted. 

When the supply is really deficient there is unfortunately not a great 
deal that can be done to replenish it. Various articles of diet and semi- 
proprietary remedies have more or less repute among physicians and laity 
alike. Among these are milk in large quantities, fish, especially shellfish, 
oatmeal and cornmeal gruel, and the various malt preparations. 

There is a widely diffused, popular idea that alcohol in one form or 
another, e.g., ale, beer and porter, promotes the secretion of milk. I dO' not 
think that this is usually true, except, perhaps, in the case of those who 
have become habituated to its use. If the patient has been in the habit of 
taking a little wine or beer with her meals, this is at all events not the best 
time for her to discontinue the custom. 

The use of pituitrin has been attended by no great success, and the same 
thing may be said of other drugs or agents which have been thought to have 
a specific action. General medical treatment, however, is important. Of 
the good efifect of such treatment, the use of iron in anaemia affords the 
best example. Arsenic combined with iron, or used when the latter proves 
ineffectual, is sometimes of value. The attendant, if in doubt, will do well 
to look carefully into the general health of his patient. For example, it 
would be unfortunate at this time to overlook a general tuberculosis. 

Local treatment by electricity, massage and the Bier apparatus has not 
been productive of marked results. 

Physiology has not as yet told us why milk is secreted at a certain time, 
nor why the supply is sometimes deficient. Hence it should not seem 
strange that as yet we have no specific. On the whole, I believe that the 
best results will be obtained by a varied and liberal diet, expert care of 
the general health, and an out-of-door life, with an abundant supply of 
fresh air at all times. 

Finally, the mother should never be allowed to continue nursing the 
child simply as a matter of sentiment. After it has once become plain 



AFFECTIONS OF BREASTS AND NIPPLES 723 

that the milk does not afford sufficient nourishment, some other form 
of feeding should be promptly instituted. In some cases a dangerous form 
of inanition develops with startling rapidity. 

How TO " Dry Up " the Milk 

If by reason of the death of the child, or for some other cause, the cessa- 
tion of nursing becomes necessary, even though there is an abundant 
supply of milk, there may be considerable inconvenience, or even pain, for 
a few days. The symptoms are much the same as those of engorgement 
of the breasts already described. A special regime was formerly supposed 
to be necessary in this class of cases. The breasts were very tightly ban- 
daged, iodide of potash and other drugs administered, and belladonna or 
some other ointment applied. For many years I have regarded all this 
as unnecessary, and have allowed the breasts to take care of themselves, 
with uniformly good results, and with far less discomfort to the patient. 
Now and then a dose of codeine may be necessary in the case of an 
extremely nervous and sensitive patient, but even this is not often required. 
A saline cathartic may be given if there is much distention. The old- 
fashioned tight breast bandage, which was a veritable torture, is entirely 
unnecessary. The whole process was a typical instance of meddlesome 
midwifery. So far as I know, Whitridge Williams was the first to subject 
this method to a systematic clinical test, and Storrs, who in 1909 reported 
a list of cases treated in Williams's Clinic, had observed no case of mastitis 
among them. 

Milk Fistula 

Now and then a milk duct is involved in the destructive process attend- 
ing a breast abscess. More often, perhaps, it is severed by the knife of an 
operator who has not learned the technic of the operation for the relief 
of this condition. The resulting fistula remains open, discharging milk 
for months, to the great embarrassment of the incautious operator. If 
simple compression of the breast fails to effect a cure, the treatment be- 
comes wholly surgical. The injection of some irritant may be tried, or it 
may even become necessary to lay open and curette the fistulous tract, 
allowing it to heal from the bottom, 

Galactorrhcea 

This term is applied to a continuous flow of milk, a flow which does 
not cease during the intervals between nursings and which may continue 
indefinitely even after the child has been removed from the breast. It may 
continue for years. In some cases the general health is affected, in others 
not. The cause is unknown and the treatment largely experimental. 

Here the tight bandage may be of some use in producing compression 
of the ducts and engorgement is to be favored rather than otherwise. It 
has been thought that the condition is associated with uterine atrophy, 



724 PATHOLOGY OF THE PUERPERIUM 

and that it sometimes disappears with the return of the menses. Hence 
uterine stimulation by hot douches and the use of electricity has been 
practised with apparent benefit. Iodide of potash, chloral, ergot and 
belladonna have been used with varying success. 

Galactocele 

By this term is meant the retention of milk in a pseudocystic cavity 
formed by the occlusion of a milk duct. The tumors are usually small, 
but exceptionally may reach enormous proportions, as in the well-known 
case in which the tumor contained ten pounds of fluid and reached to the 
groin. In doubtful cases the diagnosis is established by exploratory 
puncture. 

Supernumerary Breasts 

This curious phenomenon is of no special clinical importance, except 
when an accessory breast happens to be located in the axilla. In this 
case, owing to the proximity of large nerve trunks, the tumor may be 
quite painful. The unpleasant symptoms are usually of short duration. 
Garrigues recommends the application of ungitentnm iodi. 

Hypertrophy of the Breasts 

As in puberty, so in pregnancy, there is a physiological hypertrophy of 
the breasts, which sometimes attains such proportions as to be distinctly 
pathological. The hypertrophy is general, affecting all parts of the breast. 
Cases have been recorded in which a single breast weighed as much as 
fifty pounds. One or both breasts may be involved. The weight and the 
general health may be much affected, and the skin covering the breasts 
is so stretched as to break down, resulting in ulcerated surfaces. 

The treatment of this affection constitutes a surgical problem that need 
not be discussed here. It should be recalled, however, that the condition 
does not necessarily contra-indicate nursing, and, like fibroid tumors of 
the uterus, has a tendency to disappear during involution. 

If the patient's general health bids fair to be seriously aifected, it may 
become necessary to consider the induction of abortion or of premature 
labor. 



CHAPTER XXXIV 
OTHER COMPLICATIONS OF THE PUERPERIUM 

It would be quite impracticable for us to consider here all the affections 
and accidents which have been known to complicate the puerperal state. 
Such an encyclopaedic task would carry us far beyond the limits of a 
practical w^ork, and perhaps only serve to distract the attention from sub- 
jects of urgent and immediate importance. There are, however, certain 
conditions that are directly connected with the puerperium, or are of 
importance from the stand-point of diagnosis, and which should not be 
neglected. Of these perhaps the most characteristic and the most im- 
portant is subinvolution. 

Subinvolution 

We have already studied the processes by which uterine involution is 
brought about, and the phenomena which accompany the restoration of the 
uterus corresponding approximately to that which obtained before the 
beginning of pregnancy. Whenever involution is arrested, or seriously 
retarded, the resulting condition is known as subinvolution. 

The term subinvolution is used in a rather general way, and perhaps 
not infrequently serves to cover lack of knowledge or errors in diagnosis. 
AMthout doubt, the most common cause is infection of one kind or another. 
Indeed, the most constant symptom, at once a symptom and a result of 
puerperal infection, is subinvolution. 

Whether we believe that involution is due to fatty degeneration or to> 
autolysis, we know that its immediate cause is a local anaemia, a cutting- 
off of the blood supply to the uterine muscle, and that this local anaemia 
is due to the retraction and contraction that normally follow delivery. It 
follows, therefore, that whatever interferes with this contraction neces- 
sarily favors subinvolution. And so we find it in practice. Examples 
are to be found in the various kinds of endometritis, mostly septic in 
origin, in cervical lacerations, retention of the placenta, uterine displace- 
ments, constipation, too early resumption of household duties, etc. It is 
plain that most of the factors act, not so much by mechanically preventing 
uterine contractions, as by bringing about a venous stasis in the uterine 
circulation. In many cases both factors are present. For example, a 
fibroid may mechanically prevent uterine contraction and the coexisting 
endometritis may keep up a congestion of the uterine mucous membrane. 

Strangely enough, the general health of the patient does not seem to 
have much to do with the progress of involution. This is strikingly illus- 
trated by the fact that even in bad cases of puerperal pyaemia, without 
uterine localization, the uterus is not seriously affected. Just as in actual 

725 



726 PATHOLOGY OF THE PUERPERIUM 

labor anaemic and feeble patients often have good uterine contractions, so 
the processes of involution appear to go on without much reference to the 
general condition of the patient. Contrary, however, to the general opinion 
there are certain cases in which constitutional conditions do interfere with 
involution. An example is to be found in certain forms of cardiac disease 
attended with interference with the return circulation. Subinvolution is 
more frequent after long and difficult labors and severe operative deliveries, 
and a moderate degree is often present after the delivery of twins. It is a 
well-known fact that involution progresses more slowly when the mother 
does not nurse her child. 

Reviewing the above we may conclude that certain local causes, and, 
much more rarely, certain constitutional causes, acting locallv, tend to 
prevent the physiological anaemia of the uterus and thus retard the process 
of involution. 

Diagnosis. — As a rule the diagnosis presents little difficulty. He who 
is accustomed to watch the daily descent of the fundus, as advised in the 
chapter on the management of the puerperium, will not fail to note 
deviations from the normal. For example, the fundus is easily palpable 
above the symphysis pubis at the end of two weeks, at which time it should 
be no longer available to external palpation. The uterine enlargement is 
confirmed by internal examination, and the body of the uterus has a soft 
boggy feel, not unlike that of early pregnancy. The lochial discharge is 
prolonged and is followed by a persistent leucorrhoea. The patient com- 
plains of backache and " bearing down " sensations. Displacements often 
coexist, whether as the cause or the result of the subinvolution it is not 
always easy to say. Of these postpartum displacements we have already 
spoken. 

If the menstrual flow is absent, as is usually the case during lactation, 
the question of a possible pregnancy may have to be deferred until a second 
examination a few weeks later. 

Treatment. — Rest in bed should be enjoined, the patient, however, 
being advised to change her position frequently. Ergot may be given in 
small but frequently repeated doses, 15 or 20 minims of the fluidextract 
every four hours. This may usefully be combined in equal parts with 
the fluidextract of hydrastis. After the third week hot vaginal douches 
may be of assistance. The bowels should be kept open by some mild 
cathartic and attention paid to the general condition. 

Displacements should be corrected. Placental tissue or membranes 
should be removed by the finger or, with great care, by the forceps. The 
use of the curette is dangerous at this time and should be avoided. 

SUPERINVOLUTIOX (LACTATION AtROPHY OF THE UtERUS) 

This curious phenomenon occurs only in nursing women. The process 
of involution does not cease at its normal limit, but continues until the 
uterus becomes atrophied, sometimes in a high degree. In a case reported 



OTHER COMPLICATIONS OF THE PUERPERIUM 727 

by A. R. Simpson the uterine cavity is said to have measured but one- 
quarter of an inch in length. 

Little is known as to the cause of the condition. There seems, how- 
ever, no doubt that it is in some way connected with lactation, since it 
usually disappears after the child has been weaned. Williams considers 
that the cessation of menstruation which usually accompanies lactation is 
due to some process analogous to superinvolution. Hirst has seen uterine 
atrophy follow a curettage three times repeated. 

Displacements of the Puerperal Uterus 

After delivery the dilatable part of the uterus, i.e., the cervix and 
lower uterine segment, is thin, overstretched and flabby, while the corpus 
uteri, which requires, approximately, from four to six weeks to return 
to its normal proportions, is still many times the size and weight of the 
non-pregnant organ. Under these circumstances, bordering as they do 
upon the pathological, it is not strange that malpositions should result. 
Xow and then the normal anteflexion of the pregnant uterus becomes so 
exaggerated that an acute angle is formed between the upper and lower 
segments, preventing the escape of the lochial secretion. If no relief is 
afforded, very acute symptoms may supervene. The distention of the uterus 
by the retained secretion causes great discomfort and nervous excitement, 
and to this is soon added more or less saprsemia from decomposition of the 
retained lochia. The uterus has a " boggy," semicystic feel. The lochial 
secretion appears to be absent. With all this there may be a temperature 
of 102 or 103, and a pulse correspondingly, or even more than corre- 
spondingly, rapid. ' 

The above represents an aggravated form of the condition. In most 
cases the accumulated lochia escape before the symptoms become very 
marked. 

The treatment is simple and effective. If the finger is passed through 
the internal os and traction made in a downward and forward direction, 
the canal is straightened and there is a gush of ill-smelling lochia, which is 
followed by prompt relief and disappearance of the symptoms. It is some- 
times advised that a tube be left in the uterus for drainage, but this is 
objectionable from the stand-point of asepsis. It is usually sufficient to 
keep the patient in the dorsal position for a day or two, meanwhile securing 
uterine contraction by means of an ice-bag to the fundus and a few 
doses of ergot. 

Other Displacements 

Of the other displacements which may complicate the puerperium I 
have already spoken in connection with the management of that period, 
believing that any scheme of management which omits a search for these 
complications, and attempts to remedy them if found, is of necessity 
defective. Such a search and such an endeavor should not be relegated 



728 PATHOLOGY OF THE PUERPERIUM 

to cases obviously abnormal, but should be part of the routine management 
of every case. It is only in this way that the physician will secure freedom 
from criticism, and, what is more important, that he will fittingly discharge 
his responsibility to those entrusted to his care. 

Intercurrent Affections 

Of these something has already been said, and this need not be repeated 
here. Those only concern us especially which present problems in diagnosis. 
Prominent among these are scarlet and malarial fevers. 

Scarlet fever deserves special mention. Formerly supposed to be 
common during the puerperium, it is now known to be very uncommon. 
Its supposed frequency was in reality an index of the frequency of septic 
rashes. The septic rash may be identical with that of scarlet fever, even 
to the point of desquamation, a fact not generally known. Nowadays 
these rashes are not as common as formerly. I have discussed the diag- 
nosis elsewhere, but it is worth while to repeat here that in view of the 
responsibility involved the decision should not be made in haste. The 
other exanthemata present no special features for consideration. 

Malaria. — The diagnosis of malarial fever at this time should be 
regarded with reserve, but there is no doubt whatever that latent malaria 
has a tendency to become active during the puerperium. There are two 
conditions which simulate malarial infection very closely, vi^., puerperal 
pyelitis and puerperal pyaemia. It is not necessary to go over the clinical 
history of these conditions again, but the reader will remember that in 
both there may be well-marked chills followed by high fever and profuse 
sweating, and with intervals apparently normal. Without blood examina- 
tion the diagnosis may be for a time uncertain. 

Diphtheria. — It is not worth while to consider all the specific infec- 
tious diseases which might possibly complicate the puerperium. These 
diseases when finding their port of entry in wounds of the genital tract 
have nothing to do with the puerperium per se, but are simply rare forms 
of puerperal infection. For example, true diphtheria may occur at this 
time, but is very rare. Infection of puerperal wounds by the Klebs- 
Loffler bacillus, as determined by microscopic examination, is not true 
diphtheria as the term is ordinarily used, though it calls of course for 
treatment by the diphtheria antitoxin. It may be well to remark in passing 
that the grayish pseudodiphtheritic patches found upon the vulva and 
vagina in certain cases of infection have nothing to do with true diphtheria. 

Tetanus. — Puerperal tetanus is rare in this country, but is said to be 
quite common in India. Garrigues, a pioneer in this field, had collected 
fifty-seven cases in 1882; the number has been more than doubled since 
that time. The disease usually makes its appearance soon after delivery 
and its symptoms and course are the same as those of tetanus arising from 
the infection of other than puerperal wounds. In view of the gravity of 
the prognosis it is always worth while to try the antitetanic serum. 



OTHER COMPLICATIONS OF THE PUERPERIUM 729 

Pneumonia. — True pneumonia seldom originates during the puer- 
perium, but is seen occasionally after a premature labor brought on by the 
disease. The chief interest here centres in the problem of diagnosis. In 
most cases of death, said to be due to pneumonia, the pneumonia is of 
septic origin or perhaps a terminal process. 

Cough. — This, it is true, is only a symptom, but if violent or spasmodic 
should be suppressed, since it predisposes to hemorrhage, and to that very 
serious, if rare, accident, the detachment of an embolus. 

Typhoid. — In the cases of supposed typhoid, occasionally seen at this 
time, the diagnosis is difficult, since in severe infection the patient often 
passes into the so-called typhoid condition. If the result of the Widal 
test is negative, the case is probably one of infection. 

Diseases of the Urinary System 

Gonorrhoea, cystitis and pyelitis have been considered in connection 
with the pathology of pregnancy. I need only reaffirm here my belief that 
cystitis in the puerperium is, for the most part, a preventable disease caused 
by the unnecessary use of the catheter. The preventive treatment is most 
important and is given in the chapter on the management of the puerperium. 

The Puerperal Psychoses 

When we consider the wonderful changes wrought by pregnancy in 
the physical constitution of woman, we need not wonder that her sensitive 
and impressionable nervous system is profoundly afifected, and this in 
cases approximately normal. Often enough we recognize the change, 
although we cannot describe it. Looking into the eyes of the woman who 
realizes for the first time that she is to become a mother, we see something 
that sharpens thought and stimulates attention. She seems, not only to 
herself but to others, to be moving in a world that is new ; and so, indeed, 
she is. And as mental states, even in the non-pregnant, elude definition 
and defy classification, so do they become more puzzling and elusive in 
pregnancy. In pregnancy our patients often occupy the borderland 
between physical health and disease, and at this time the borderland 
between sanity and insanity, always ill defined, is much wider than at 
other times. 

Thus it happens that mental disturbance during pregnancy usually 
takes forms that do not lend themselves well to classification. They are 
rather exaggerations or perversions of mental peculiarities or tendencies 
from which no one is free. An exaggerated melancholy, a condition of 
profound depression, is the most common, and is most likely to occur 
during the early months. It is probably due to the anaemia and malnutri- 
tion so common at this time. Stuporous and confusional states are less 
common and more likely to occur at a later period of pregnancy. Toxcxmia 
probably plays some part in their etiology. Maniacal conditions are hardly 



730 PATHOLOGY OF THE PUERPERIU:M 

ever seen. ]\Iost of the insanities of pregnancy, unless of hereditary origin, 
disappear shortly after delivery. 

According to the teachings of modern psychiatry there is no special type 
which is peculiar to pregnancy or the puerperium, nor is either of these, 
properly speaking, a cause of mental disease. Either, however, may be 
the occasion of the lighting up of some smoldering neuropathic tendency. 

According to Krapelin, some sort of morbid psychosis may be noted in 
7 per cent, of puerperal cases, the number originating during pregnancy 
being somewhat less. As a matter of fact, if we exclude the minor dis- 
turbances which, although coming within the bounds of some scheme of 
classification, are nevertheless usually passed over as mere " moods " 
or eccentricities, and at the same time consider the long duration of 
pregnancy as compared with the few weeks comprising the puerperal 
period, we will find that mental disturbance is very much more frequent 
during the puerperium than during the months preceding deliver}^ 

Why is this the case? The question appears to be answered by the 
fact that the psychoses most frequently seen at this time are the infective- 
exJiaiistire psychoses. It is hardly necessary to tell anyone that infection 
and exhaustion are characteristic features of the abnormal puerperium. 
Of what produces infection we need not speak again. The most prominent 
type of infective psychosis is that of febrile delirium. The duration and 
severity of this constitutes in some degree a measure of the mental 
stability of the patient. The delirium is usually brief, follow^s the febrile 
movement, and differs little except in degree from ordinary fever delirium. 
It is important to remember that the fever of infection is not often, at least 
in its early stages, accompanied by delirium. 

Next in order come two well-defined psychoses which may either follow 
the form just mentioned, or develop independently as the result of exhaus- 
tion. These are collapse delirium and acute confusional insanity. 

Collapse delirium may follow difficult labor, unusual loss of blood, or 
severe mental shock. It is characterized by an acute onset, a condition of 
confusion which may be mild in character, constituting only a marked 
perplexity or, in other cases, attended by psychomotor restlessness, with 
profound clouding of consciousness, complete disorientation, dreamy illu- 
sions, hallucinations, and delusions. The course is rapid, usually only one 
or two weeks, and recovery is the rule. Defective heredity is said to be 
present in one-half the cases. The above description will be recognized at 
once by all those who have worked in the maternity hospitals of a great city. 
According to my experience it is far less frequent in private practice. A 
similar condition sometimes follows eclampsia. Here we might speak 
perhaps of a toxic-exhaustive psychosis. 

Acute confusional insanity develops a little later as the result of 
exhaustion plus the anaemia of lactation, and lasts for some months. The 
prognosis is favorable. 

A large proportion of the mental disturbances that complicate the puer- 



OTHER COMPLICATIONS OF THE PUERPERIUAI 731 

peral period, nearly one-half are of the stuporous type and come under the 
classification of dementia prcecox and its allied types. Most of these cases 
run a favorable course. Those, however, that develop before labor or 
during lactation offer a doubtful prognosis. 

Finally, there is another type of puerperal psychosis, manic-depressive 
insanity. This includes what were formerly known as puerperal mania 
and puerperal melancholia, and were supposed to have some specific con- 
nection with pregnancy and the puerperium. They are now regarded as 
links in the chain of manic-depressive insanity, a psychosis which has a 
tendency to return, in some form, at dift'erent periods in the life of an 
individual. Defective heredity has been found in from 70 to 80 per cent, 
of all cases. ^Nlany cases referred to by the older writers as mania are 
in reality cases of delirium. 

The above classification, which is that of Brink, seems to me to afford 
a good groundwork for the study of a fascinating, if not very practical, 
subject which, of course, cannot be taken up here, and concerning which 
few obstetricians can speak with authority. If I may venture a word of 
advice, however, I would urge the reader not to forget the two types, 
febrile, and collapse delirium. Occurring, as they do, shortly after delivery, 
they are certain to come under his observation sooner or later, and since 
they are seldom properly described may be the source of mistakes in 
diagnosis and of errors in treatment. 

For the diagnosis and treatment of the other forms the reader is 
referred to works on psychiatry, and is advised to consult a psychiatrist 
whenever this is possible. A few general suggestions, however, may be 
of service. In the first place the attendant should see that his patient 
does not have the opportunity to injure herself or her child. No regrets 
or excuses will atone for the neglect of this precaution. Hypnotics may 
be necessary, but should be used with discretion. For example, it would 
not be wise to give cardiac depressants in a case of exhaustive delirium. 
The modern hydropathic treatment of these conditions should be studied. 
Sometimes the prolonged warm bath (immersion bath) is of marked 
benefit, and, again, the cold pack, if not contra-indicated, is to be preferred. 
If the patient is alarmed at the idea of the bath, she may first be quieted 
by suitable medication. 

Postpartum Paralysis in Mother and Child 

I have referred elsewhere to the neuralgic pains or " cramps " that are 
so often observed during labor and that are caused by the pressure of the 
child's head upon nerves that pass over the brim of the pelvis. It is easy to 
imagine how exaggerated or long-continued pressure of this kind may result 
in lesions sufficient to account for the neuralgic pains that sometimes long 
outlast the puerperium, and even for the paralysis that sometimes follows 
it. The affection is usually unilateral, corresponding to the side toward 
which the occiput is directed. The present tendency is to attribute the 



732 PATHOLOGY OF THE PUERPERIUM 

condition rather to the pressure of the head in delayed labor than to the 
employment of the forceps. Contracted pelvis has been cited as a cause. 
Unusual size of the head would be a parallel instance. It is said to result 
less frequently in the case of a flat pelvis because the projecting- promon- 
tory prevents the head from descending far enough to be subjected to 
serious pressure. ]\Iy own observation leads me to believe that it is 
usually the result of the premature or unskilful use of the forceps. 

It is the region supplied by the external popliteal nerve that is most 
affected. This nerve receives fibres from the fourth and fifth lumbar 
cords before it unites with the sacral plexus, and is most exposed to pres- 
sure in its passage over the brim of the pelvis. The result of pressure 
on this nerve is paralysis of the anterior and outer muscles of the leg, that 
is of the flexors of the foot and of the extensors of the toes, so that the 
foot is flexed upon itself (plantar flexion) and turned inward. Even 
though the injury has not been sufficient to cause paralysis, there may be 
pain and numbness along the distribution of the affected nerves. 

Hsemiplegia is, of course, a possible occurrence during the puerperium 
as at other times. Factors that favor its occasional occurrence at this 
time are eclampsia and venous thrombosis. 

Neuritis has many times been noted during the puerperium. The best 
description in English is that of Garrigues. He recognizes two types, the 
localized or mild type, and the general or severe type. The localized form 
may affect either the arm or the leg, more commonly the former. Even 
this, as I have witnessed it, hardly deserves the term mild, except perhaps 
as compared with the generalized form. There are the usual symptoms of 
an aggravated neuritis, e.g., severe pain, tenderness along the course of 
the affected nerves, numbness, loss of power in the innervated muscles, etc. 
In bad cases the arm or leg may become swollen or oedematous. The 
nerves usually involved are the median and ulnar nerves, and the sciatic. 
The attack may be prolonged and the suffering severe, but recovery is 
the rule. 

In the generalized form many nerves may be involved at one time, even 
those of the eyes and of respiration and deglutition. The prognosis is 
grave. 

Until we know more of the metabolism of pregnancy we shall be in 
doubt as to the cause of puerperal neuritis. It is now usually put down as 
toxaemia, and some color is lent to this theory by the fact that it has been 
obsen-ed in cases which have been subject to the vomiting of pregnancy. 
Local causes undoubtedly play some part, since the condition is not infre- 
quently associated with a pelvic exudate or a femoral phlebitis. 

Other causes of pain in the lower extremities, and difficulty in walking, 
which should be borne in mind, are injury or even rupture of the symphysis^ 
or one of the sacro-iliac joints, during difficult labor, and, most common 
of all in my experience, varices of the leg or thigh, sometimes rather deeply 
seated, and often unnoticed or disregarded by the patient. 



OTHER CO:\IPLICATIOXS OF THE PUERPERIUM 733 

Duchenne's Paralysis 

A\'e have already become familiar with the transient facial paralysis 
of the new-born, which so often develops after forceps operations in which 
much traction has been made, and which soon becomes familiar to every 
practitioner. 

With the exception of this form, Duchenne's paralysis is the most com- 
mon and typical met with in the new-born. The affected area involves 
the distribution of the fifth and sixth motor roots of the brachial plexus, 
and aft'ects chiefly the flexors and internal rotators of the arm. In a typical 
case the arm hangs at the side with the hand turned inward. This form of 
paralysis is usually attributed to compression or stretching of the nerves 
in the delivery of the after-coming head, especially when the Prague 
method is used, or, in vertex cases, to traction by the finger in the axilla, 
or even to direct compression with the forceps. 

Prevention. — This is a highly important matter. The Prague method 
of delivering the after-coming head should be banished from the text-books. 
In the ]\Iauriceau method pressure should always be made upon the after- 
coming head whenever there is any difficulty in delivery. The head is to 
be pushed, not pulled, through the pelvic canal. The final movement is one, 
not of traction, but of extension. 

I do not think there is much danger of compressing the brachial plexus 
by the forceps tips. Indeed, this is hardly possible if the head is of normal 
size and well flexed. It might happen, however, as Stolper has shown in 
cases of marked extension, e.g., in presentations of the face and brow. 
The correct method of applying the instrument in face presentations is 
shown in Fig. 362. In difficult delivery of the shoulders lateral flexion of 
the neck should not be too pronounced. 

Delayed Chloroform Poisoning 

As we have seen in connection with the subject of postpartum hemor- 
rhage, chloroform, while hardly ever the direct cause of death during labor, 
strongly predisposes to uterine relaxation after delivery. Then, too, it can 
hardly be doubted that its eft"ect as a cardiac depressant, when addod to 
the shock of an operative delivery, may hasten a fatal issue. To these 
charges against this once favorite anaesthetic has recently been added 
another, that of '' secondary " chloroform poisoning. 

The symptoms of this condition make their appearance two or three 
days after delivery and consist of apathy, with mental and physical depres- 
sion which may deepen into coma and death. Moderate evening fever 
may be present, and jaundice occurring early is highly significant. 

Williams reports a case which terminated fatally, the autopsy showing 
lesions in the liver similar to those produced experimentally and to those 
which are found after death in eclampsia. The patient was under the 
influence of chloroform, which she took badly, for over an hour. 



734 PATHOLOGY OF THE PUERPERIUM 

I have myself seen one case which I regarded as one of chloroform 
poisoning, although of a milder type. This patient, who also took the 
anaesthetic badly, consmiied a good deal of chloroform during a difficult 
forceps operation, which, however, was less than an hour in duration. 
Two or three days after delivery she showed evidences of mental and 
physical apathy which, however, never deepened into unconsciousness. 
There was a slight evening rise of temperature, 101-102, and distinct, 
though not very marked, jaundice. The patient recovered. 

Puerperal ^Myalgia 

Observation has led me to believe that the puerperal patient is peculiarly 
subjec"" to attacks of acute myositis, or, as it is popularly called, muscular 
rheumatism. At all events I have seen such attacks so often that I believe 
it worth while to call attention to them. The phenomena are essentially 
those of " stiff neck," lumbago, etc., and vary according to location. The 
cause is most often to be found in the exposure of some part of the body 
to a prolonged current of air. Predisposing causes are the relaxation of 
the muscles and the free perspiration so characteristic of this period. 



INDEX 



Abdomen, enlargement of, in pregnancy. 

pendulous, in pelvic contraction, ^:^\i 
striae of, in pregnancy, 24 
unusual size of, in pregnancy, 64 
Abdominal aorta, compression of. 466 
binder, in puerperium, 195 
muscles, in labor, 114 

inertia of, 358 
wall, changes in, in pregnancy, 17 
distention of, 39 
in multiparas, 10 
in primiparae, 10 
Abortion, classification of, 312 
clinical history of, 312 
• criminal, 309 
curettage in, 319 
decidual. 310 
definition of, 308 
differential diagnosis, 313 
ether in induction of, 544 
etiology of, 308 
in backward displacements of uterus, 

240 
incidental, 309 
induction of, 567 

indications for, 567 
technic of, 568 
inevitable, 315 
mechanism of, 310 
missed, 320 
predisposition to, 314 
threatened, 313 
treatment of, 313 
tubal, 313, 2)'2-2, 
Abscess of breast, 717 
pelvic, 692 
submammary, 721 
Accidental hemorrhage, concealed, 484 
de Ribes bag in, 486 
ergot in, 486 
frequency of, 483 
pituitrin in, 486 
treatment of, 485 
vaginal Csesarean section in, 565 
Acetonuria in pregnancy, 22 

in the puerperium, 193 
Acute yellow atrophy of liver, 280 
Adherent placenta, 177 
Adrenalin in vomiting of pregnancy, 278 
After-coming head, forceps to, 605 
in pelvic contraction, 534 
perforation of, 676 
After-pains. 197 
Agalactia, 722 



Ahlfeld's method of determining period 

of pregnancy, 45 
Albuminuria in eclampsia, 254 

in pregnancy, 22 

in the puerperium, 193 
Amnion, diseases of, 350 
Amniotic adhesions, 352 

bands, 352 

lluid, function of, 112 
diminished, 352 
excessive, 350 
Ampullar pregnancy, 323 
Anaemia in pregnancy, 19 

in the puerperium, 192 
Anaesthesia in forceps operation, 585 

in induction of abortion, 568 

in labor, 156 

chloroform, 156 

ether, 156 

method of administration, 156 

selection of anaesthetic, 156 

in obstetric surgery, 543 

scopolamine, 157 
Anencephalus, 'iZI 

Anteflexion of postpartum uterus, 183 
Antepartum examination, 63 

hemorrhage, 483 
Anteversion of pregnant uterus, 10 
Antisepsis in labor, 143 

in obstetric surgery, 547 
Antistreptococcic serum, 708 
Appendicitis, in pregnancy, 305 
Areola of breasts in pregnancy. 42 

glands of Montgomery in, 42 
Arterial tension in labor, 135 
Artificial respiration, 410 
Asepsis in labor, 143 

in obstetric surgery, 547 
Asphyxia neonatorum, 405 

after-care in, 425 

general precautions in, 425 

indications of impending, 409 

in premature infants, 425 

livida, 411 

methods of treatment, 410 

pallida, 414 

preventive treatment, 406 
oxygen in, 406 

summary of treatment in, 426 

tongue traction in, 413 

varieties of, 405 
Assimilation pelvis, 500 
Asthma in pregnancy, 299 
Atony in hydramnion, 351 

in postpartum hemorrhage. 459 
735 



72>6 



IXDEX 



Atony of uterus, after multiple labor, 

218 
Atresia of cervix, vagina, vulva, 250 
Attitude of fcetus, 84 
Axis-traction forceps, 595 

Bag of waters, 43 

action of, 112 
Ballottement in diagnosis of pregnancy, 

Bandl s contraction ring, 365 
Barnes bags, 553 
Basiotribe of Tarnier, 672 
Bath, during labor, 143 

of new-born child, 204 
Baudelocque's method in expulsion of 

placenta, 116 
Binder, abdominal, in puerperium, 196 
Bladder, attention to, in puerperium, 199 

distention of, 461 

fistula, in pelvic contraction, 526 

in obstetric surgery, 546 

mucous membrane of, in pregnancy, 

23 
Blood, changes in, in pregnancy, 19 
in the puerperium, 192 

pressure, in pregnancy, 256 
Blot's perforator, 666 
Bones, changes in, in pregnancy, 24 

puerperal osteophytes, 25 
Bossi's dilator, 558 
Bougie in induction of labor, 571 

disadvantages of, 572 
Bowels, after perineal repair, 443 

in obstetric surgery, 546 

in pregnancy. 58 
Brachial plexus, compression of, in labor, 

Breasts, abscess of, 717 
incision in, 721 
caked, 714 

care of, in puerperium, 203 
changes in, in pregnancy, 42 
continuous flow from, ^22, 
deficient secretion of, 722 
drying up secretion of, '/2i 
engorgement of, 712 
fistula in. '/2-:i, 
hypertrophy of, 724 
inflammation of. 717 
massage of, 714 
retention of milk in, 724 
striae on, in pregnancy, 42 
supernumerary, 724 
symptoms referable to, in preg- 
nancy, 30 
Breech presentation. 385 

delivery of after-coming head 

in, 624 
delivery of impacted breech in, 

394 
diagnosis of, 387 



Breech presentation, effect upon labor 

of, 391 
etiology of, 386 
fetal mortality in. 390 
forceps in, 394, 602 
location of fetal heart-sounds 

in, 388 
mechanism in, 386 
posterior rotation of breech in, 

387. 
of occiput, in, 628 
release of extended arms in, 621 
treatment of, 391 
Brow presentation, 400 

choice of operative measures, 403 

configuration of head in, 402 

diagnosis of, 403 

etiolog>- of, 401 

extraction of after-coming head 

in, 403 
forceps in, 403 
mechanism in, 401 
prognosis in, 403 
version in, 403 

Csesarean section, after-treatment of, 645 
delivery of placenta in, 641 
ergot, preliminary to, 642 
ether-oxygen in, 486 
extra-peritoneal, 649 
in accidental hemorrhage, 486 
in contracted pelvis. 528, 536 
indications for, 636 
in placenta praevia, 482 
in prolapse of cord, 428 
Porro operation, 646 
post-mortem, 652 
prognosis of, 637 
repeated, 649 
salient points in, 646 
supra-symphyseal, 649 
technic of, 639 
time for operation, 62^7 
vaginal, 559 

Caput succedaneum, 207 

Carcinoma of cervix, in pregnane}-, 238 

Cardiac disease, in pregnancy. 295 

Catheter in obstetric surgery, 546 
in puerperium, 199 

Caul, 114 

Cephalhaematoma, 208 

Cephalic version, indications for, 635 

Cephalotribe. Tarnier's, 671 

Cervical incisions. 566 

lacerations, in labor, 445 

Cervix, annular sloughing of, 526 
apparent shortening of, 12. ^z 
atresia of. 250 

carcinoma of. in pregnancy, 238 
changes in, in pregnancy, 12 
condition of, at or near term, 14 
in placenta praevia, 479 



INDEX 



737 



Cervix, dilatation of, in normal labor, no 
instrumental, sss 
manual. 550 
external os, 15 
hemorrhage from, 471 
incisions of, in labor, 566 
in multipara;, 15, 129 
in primiparie, 14, 129 
internal os, 15 
laceration of, in labor. 445 
cedema of, in pelvic contraction, 526 
rigidity of, 356 
Chadwick's sign of pregnancy, 37 
Champetier de Ribes bag, 553 
Chloasma in pregnancy. 23, 307 
Chloroform in labor, 156 

in obstetric surgery, 543, 545 
poisoning, delayed, yss 
Chorea in pregnancy. 281 
Ch-orio-epithelioma. 348 
Chorion, cystic degeneration of, 346 

epithelioma of, 348 
Circulatory system, changes in, in preg- 
nancy, 18 
diseases of. 295 . 
embolism in pregnancy, 299 
minor disturbances of, 20 
varicose veins, in pregnancy, 
298 
in hydramnion, 351 
Cleidotomy, 682 
Coitus during pregnancy, 58 
hemorrhage following, 58 
infection due to, 58 
Colles's law, 283 
Colly er's pelvimeter, 513 
Conjugate diameter, diagonal, 518 
external, 514 
internal, 518 
true, 519 
Constipation in pregnancy, 21 

in the puerperium, 200 
Contracted pelvis, at outlet, 500 

Caesarean section in, 528, 536 
choice between forceps and ver- 
sion, 530 
classification of, 490 
craniotomy in, 537 
effect of, on clinical course of 
labor, 525 
on course of pregnancy, 521 
on foetus, 526 
on maternal structures, 526 
on mechanism of labor, 522 
etiology of, 488 
frequency of, 487 
history of, 487 

pelvimetry in diagnosis of, 510 
position of uterus in, 525 
pubiotomy in, 536 



Contracted pelvis, technic of forceps 
operation in, 532 
treatment of, 527 
versi n in, 534 
Contractions of uterus, force exerted 
by, 133 
in beginning labor, 130 
intermittent, in pregnancy, 42 
Coxalgic pelvis, 503 
Cranioclast of Braun, 669 
Craniotomy, after decapitation, 680 
cephalotripsy, 671 
contra-indications for, 665 
in contracted pelvis, 537 
indications for, 664 
in face presentations, 400 
in hydrocephalus, s^y 
in multiple labor, 221 
in vaginal hysterotomy, 563 
perforation in, 666 
upon after-coming head, 676 
Crede's method of expressing placenta, 

175 
Curettage in abortion, 319 

repeated, followed by uterine 
atrophy, y2y 
Cutaneous affections in pregnancy, 306 
chloasma, 23, 307 
herpes, 307 

impetigo herpetiformis, 307 
pruritus, 306 
Cystitis in pregnancy, 301 

in the puerperium, 301 
Cystocele, 252, 442 

Decapitation, craniotomy after, 680 
extraction of head after, 679 
jn transverse position, 676 
Deciduoma malignum, 347 
Delayed labor, 357 

De Ribes bag in accidental hemorrhage, 
486 
in placenta prsevia, 481 
in prolapsus funis, 429 
Diabetes in pregnancy, 22 
Dilatation of cervix, artificial, 550 

in accelerating progress of 

labor, 573 
in induction of abortion, 569 
preliminary to version, 612 
steel dilators for, 557 
summary of methods for, 566 
Diphtheria in the puerperium, 728 
Disinfection of hands, 143 

of vulva, 146 
Displacements, of pregnant uterus, 240 

of puerperal uterus, 727 
Double monsters, 338 
Douche, intra-uterine, 464 
vaginal, 706 

in subinvolution, 726 



738 



INDEX 



Duchenne's paralysis, 733 
Diihrssen's cervical incisions, 566 
Duncan's mechanism, m expulsion of 

placenta, 117 
Dry labor, 113, 150 
Dystocia, 333 

following vaginal fixation, 243 

Eclampsia, accouchoiioit force in, 268 
anaesthesia in, 269 
Csesarean section in, 269 
cervical dilatation in, 554 
clinical history of, 264 
convulsions in, 264 
differential diagnosis of, 267 
etiology of, 261 
oxygen in, 271 
pathology of, 263 
period of pregnane}'. 264 
prognosis, 266 
treatment, 267 
urine in, 255, 264 
Embolism in the puerperium, 209, 697 
Embryotomy, 664 
Endometritis, in pregnancy, 223 
decidual, acute, 223 
atrophic, 225 
chronic, 223 
putrid, 691 
Episiotomy, 251 

Ergot in accidental hemorrhage, 485 
in postpartum hemorrhage, 463 
in subinvolution of uterus, 726 
preliminary to Csesarean section, 642 
use of, in abortion, 363 
in labor, 197 
Erysipelas in pregnancy, 294 
Ether in labor, 156. 161 

in obstetric surgery, 544 
Evisceration, 680 
Evolution, spontaneous. 380 
Examination, antepartum, 63 
external, 64 
internal, 82 
during labor, 151 
Expression of foetus, 364 

of placenta, 175 
External version, 630 
Extraperitoneal Csesarean section, 649 
Extra-uterine pregnancy. 322 

blood examination in, 328 
diagnosis of, 324 
differential, 329 
early symptoms in. 324 
in advanced case, 328 
disposition of placenta in, 333 
etiology of, 323 
haematoma in, 332 
terminations of, 323 
treatment of. 330 
tubal rupture in, 324 
Eyes of new-born infant, 172 



Face presentations, conversion of, to 
occiput, 399 

diagnosis of, 396 

etiology of, 395 

mechanism of, 396 

perforation in, 400 

treatment of, 398 
False labor, 128 

Feeding of new-born infant, 206 
breast, 207 
by wet-nurse, 207 
Fetal head, anatomy of, 100 

moulding of, 126 
heart-sounds, auscultation of, 79 

as evidence of pregnancy, 39 

location of, 82 
mortality in labor, 404 
movements, 43 
syphilis, 283 
Flattening of the pelvis, 492 
Foetus, abdominal enlargement of, 338 
anomalies of, 334 
attention to, in labor, 170 
attitude of, 84 
diagnosis of death of, 46 
dropsy of, 338 

Kristeller's expression of, 364 
length of, 46 
maceration of, 285 
malpositions of, 368 
position of, 84 
presentation of, 87 
rigor mortis of, 338 
Forceps, anaesthesia in use of, 584 

application of, in contracted pelvis, 

in breech presentation, 602 
530 

in brow presentation, 403 

in face presentation. 603 

in multiple labor, 221 

in occipito-anterior positions, 586 

in occipito-posterior positions, 
600 

to the after-coming head, 605 
axis-traction. 595 
choice of, 577 

conditions necessary for use of, 582 
facial paralysis due to, 733 
final examination before using, 585 
high operation, 594 
history of, 574 
indications for, 578 
justification for use of, 581 
low operation, 586 
mechanics of operations, 582 
median operation, 591 
Simpson. 576 
summary, 606 
Tarnier, 596 

version compared with, 580 
Fundus uteri in accidental hemorrhage. 
485 



INDEX 



739 



Fundus uteri, outlining of pregnancy, 67 
position of, in the puerperium, 
184 
Funic souffle, 39 

Galactocele. 724 

Galactorrhoea, -i}, 

Galbiati's falcetta, 653 

Glandular system in pregnancy, 21 
enlargement of pituitary body, 22 
hypertrophy of suprarenal capsules, 
21 

Gloves, gauntlet, 145 
in labor, 145 
in obstetric surgery. 547 
methods of sterilizing, 145 

Gonococcus in pregnancy, 227 

in the puerperium. 688, 694 

Goodell's dilator, 558 

H?ematoma in extra-uterine pregnancy, 

of vagina, 444 
of vulva, 444 
retroplacental, 116 
treatment of, 444 
Hank's dilators, 558 
Heart, changes in, in pregnancy, 18 
Hegar's dilators, 558 

sign of pregnancy, 34 
Hemorrhage, accidental, 483 
cervical, 471 
due to lacerations, 443 
ergot in, 462, 485 
hypodermoclysis in. 470 
in inversion of uterus, 456 
in placenta praevia, 478 
morphine in. 471 

postpartum, character of pulse in, 
468 
concealed, 462 
diagnosis of, 461 
etiology of, 459 
late, 473 
shock, physical as a cause of, 

461 
treatment of, 462 
saline infusion in, 469 
Hemorrhoids in pregnancy, 19 
Hernia of pregnant uterus, 246 
Herpes gestationis, 307 
Hirudin in eclampsia, 272 
Hour-glass contraction of uterus, 365 
Hydatidiform mole, 346 
Hydramnion, etiology of, 351 
in multiple pregnancy, 217 
symptoms of, 350 
treatment of, 351 
uterine exhaustion in, 461 
Hydrocephalus, influence on labor of, 

335 
perforation in, :i)^'] 



Hymen, imperforate, 250 
Hyperemesis gravidarum, adrenalin in, 
278 

diet in, 279 

drugs in, 278 

etiology of, 274^ 

oxygen inhalation in, 279 

in induction of abortion, in, 280 

periods of, 276 
Hypertrophy of breasts, 724 

of uterus in pregnancy, 2 
Hypodermoclysis, 470 
Hysterotomy, anterior vaginal, 559 

delivery of foetus after, 563 

Impetigo herpetiformis, 307 
Incisions of cervix, 566 
Induction of abortion, 567 

of premature labor, 570 
Inertia, uteri, 354 

of abdominal muscles, 358 
Infarcts of placenta, 342 
Infection, after pressure necrosis, 526 
prevention of, in puerperium, 195 
puerperal, 683 
Influenza in pregnancy, 293 
Innervation of uterus, 109 
Instruments, disinfection of. 146 
Intra-uterine douche tube, 464 

tamponade, 464 
Inversion of uterus, artificial, 455 
dangers of. 457 
diagnosis of, 456 
hemorrhage in, 456 
shock in, 456 
spontaneous, 455 
treatment of, 458 
Involution of uterus, 182 
Isthmic pregnancy, :ii22t 

Joints, changes in, in pregnancy, 16 
motion in pubic symphysis, 100 
Justo major pelvis, 508 
Justo minor pelvis, 495 

Kidneys in eclampsia, 263 

displacement of, in pregnancy, 23 
Knots of umbilical cord. 345 
Krause's method of inducing labor. 571 
Kristeller's expression of foetus, 364 
Kyphotic pelvis, 505 

Labor, abdominal muscles in, 114 
anaesthesia in, 156 
anomalies in forces of, 353 
arterial tension in, 135 
atypical, 136 
bath in, 143 

bed, preparation of, 142 
cause of, 107 

changes in outline of uterus in. 135 
chill following. 189 



740 



INDEX 



I/abor, clinical phenomena of, 128 
colling of cord, 168 
cystocele in, 2^2 
delayed, Z':i7 

expulsion of placenta, 116 
external examinations, value of, 148 
false, 128 

fetal mortality in. 404 
first stage, conduct of, 154 
force exerted in, 133 
induction of, 567 
laceration of cervix in, 445 

of perineum in, 431 
limitation of internal examinations 

in, 147 
management of, 138 
mechanism in occiput presentation, 

multiple, clinical course of, 217 

management of, 218 

prognosis of, 222 

uterine exhaustion in, 461 
pains of, 133 
pathology of, 153 
perineum in, 136 
physiology of, 107 
precipitate, 366 
prediction of date of, 44 
premature, 308 

rupture of membranes in, 113 
second stage, conduct of, 162 

attention to foetus. 170 
third stage, conduct of. 172 

prevention of hemorrhage, 174 
tumors complicating. 229 
tying of cord, 171 
vaginal examination in. 151 
Lacerations of anterior vaginal wall, 
422 
causes of, 443 
hemorrhage following, 

443 
lisematoma, 444 
of cervix, 445 
■of perineum, in labor, 431 

repair of, 432 
of vagina, 445 
rupture of uterus, 446 
Lactation, 193 

atrophy of uterus. 726 
Ladinski's sign of pregnancy, 35 
Laryngeal tube, introduction of, 414 
Laxatives in pregnancy. 58 
in the puerperium, 200 
Legholder^ 543 
l^ucocytosis in labor. 135 

in the puerperium, 192 
Liquor amnii. 112 

deficiency of, 352 
excess of, 350 
Lithotomy position, exaggerated, in 
pelvic contraction, 536 



Liver, acute yellow atrophy of, in preg- 
nancy, 280 
Lymphatic glands in pregnancy, 21 
Lochia, 191 
Lochiometra, 685 

^Malarial fever in pregnane}-, 293 

in the puerperium, 728 
IManagement of pregnancy, 54 
jManual removal of placenta, 177 
INIastitis. puerperal, 717 
Mauriceau's manoeuvre, 625 
McDonald's sign of pregnancy, 35 
IMembranes, premature rupture of, 113, 

in contracted pelvis. 529 
in transverse position, 2>7': 
unruptured, 113 
Menstruation, cessation of, in pregnancv, 

2% 
jNIental, condition in pregnancy, 24, 30 

hygiene in pregnancy, 60 
Michjelis's rhomboid. 509 
Milk fistula, 723 
Montgomery's glands, 42 
Multiparity, diagnosis of, 47 
Multiple pregnancy, acardia in, 215 
clinical history of, 217 
development of, 212 
diagnosis of, 215 
hydramnion in, 217 
treatment of, 218 
IMusculature of pregnant uterus. 3 
IVIyalgia in the puerperium, 734 
Myomata of uterus, effect on progress 
of labor. 231 
of pregnancy. 230 
diagnosis. 233 
prognosis, 229 
treatment, 22,Z 

Njegele pelvis, 502 

Nausea and vomiting in pregnancy, 29,. 

273 
Nephritis in pregnancy, acute, 300 

chronic, 300 
Nervous system in pregnancy, 30 
neuralgia, 306 
neuritis, 305 
paralyses, transient, 306 
pruritus, general and local. 305 
New-born infant, asphyxia of, 405 
bath of, 204 
care of, 206 
clothing. 206 
length of. 46 
ligation and care of cord of, 

J71 
nursing, 207 
Nipple shield. 205 
Nipples in pregnancy, care of, 59 
changes in, 42 



INDEX 



741 



Nipples, erosions of, 714 
fissures of, 717 
in the puerperium, 204 

Oblique deformities of pelvis, 502 
Obstetrical operations, anaesthesia in, 

543 
attention to foetus durnig, 548 
care after, 548 
chloroform in, 545 
final examination before. 548 
general indications for, 540 
nitrous oxide in, 546 

Occipito-posterior positions, atypical 
mechanism of, 371 
causes of delay in, 369 
clinical history of, 371 
effect upon labor of, 37-2 
etiology of, 368 
indications for treatment in, 2)72> 

Occipito-sacral position. 374 

Oligo hydramnion, 352 

Ophthalmia neonatorum, prophylaxis of, 
172 

Os externum, 15 
internum, 15 

Osteomalacia, 506 

Outlet contraction of pelvis, 500 

Ovarian pregnancy, 323 

cysts, diagnosis of, 2^-; 

effect on pregnancy and labor, 

treatment in labor, 238 
in pregnancy, 237 
Ovary, position of, in pregnancy, 12 
Oxygen in antenatal asphyxia. 407 
in eclampsia, 271 

in prevention of asphyxia neona- 
torum, 407 
in toxsemia, 260 

Paralysis after labor in pelvic con- 
traction. 526 

Duchenne's, y^tZ 

in the puerperium, 731 

transient, in pregnancy, 306 
Parturition, 94 
Pathology of labor, 353 

of pregnancy, 223 

of the puerperium, 683 
Pelvic abscess, 692 

cellulitis, 708 

contraction, 487 

floor, changes of, in labor, 123 

changes of, in pregnancy, 16 

hsematocele, 331 

inlet, diameters of, 511 

joints, motion in. 100 

outlet, diameters of, 514 

peritonitis. 693 
Pelvimeter, 512 

caution as to accuracy. 513 



Pelvimetry, external, 510 

internal, 517 
Pelvis, anatomy of, 94 

assimilation, 500 

bilateral Neegele, 504 

changes in joints of, in pregnancy, 
16 

contracted, 487 

coxalgic, 503 

cretin dwarf, 498 

diameters of, 510 

dwarf, 498 

enlargement of, in pregnancy, 17 

flat, 492 

and generally contracted, 498 
rhachitic, 494 
simple, 493 

funnel, 500 

generally contracted, 495 

generally enlarged, 508 

infantile, 100, 489 

justo major, 508 

justo minor, 495 

kyphotic, 505 

masculine, 99 

movements of, in joints, 99, 100 

N^gele, 502 

nana, 498 

normal female, 94 

obliquely deformed, 502 

obtecta, 505 

osteomalacic, 506 

outlet contraction of, 500 

rhachitic, 494 

Roberts, 504 

scoliotic, 505 

spinosa, 507 

split, 508 

spondylolisthetic, 505 

transversely contracted, 504 
Pendulous abdomen in pelvic contrac- 
tion, 536 
in pregnancy, 59 
Perforation of retroflexed uterus, 318 
Perforator of Simpson, 666 
Perineal laceration, 431 
Perineum, change of, in labor, 136 
in pregnancy, 16 

laceration of, in labor, 431 

protection of, 163 

repair of, 431 
Phlebitis, 298, 698 

Pigmentation of skin in pregnancy, 23 
Pinard's manoeuvre, 392 
Pituitrin in accidental hemorrhage. 486 

in delayed labor, 362 

in induction of labor, 573 

precautions in use of, 362 
Placenta, abnormal insertion of cord, 
344 

abnormalities of, 338 

adherent, 177 



742 



INDEX 



Placenta, battledore, 343 

bipartita, 341 

circumvallata, 340 

cysts of, 344 

delivery of, normal, 174 

in Csesarean section, 641 
in vaginal hysterotomy, 563 

expression of, by Crede's method, 

infarcts of, 342 

in multiple labor, 213 

in syphilis, 285 

manual removal of, 177 

marginata, 342 

membranacea, 340 

mj'xoma fibrosum of, 342 

prasvia, 474 

C?esarean section for. 482 

condition of cervix in, 479 

diagnosis of, 476 

digital examination in, 477 

ether in, 544 

etiology of, 475 

fetal mortality in, 479 

frequency of, 475 

prognosis in, 478 

recurrence of, 477 

symptoms of, 476 

vaginal tamponade in, 479 
premature separation of, 483 
retained, 175 
separation of, 115 
succenturiata, 338 
velamentous insertion of cord into, 

344 
Placental expulsion by mechanism of 
Baudelocque, 116 
by mechanism of Duncan, 117 
forceps, 570 

danger of, 726 
Pneumonia in pregnancy. 293 

in the puerperium. 729 
Podalic version, breech extraction in, 
620 
contra-indications, 610 
delivery of after-coming head, 

624 
for placenta prsevia, 559 
in brow presentation, 403 
indications for, 609 
in face presentation, 399 
in pelvic contraction, 534 
in transverse position, 380 
release of extended arms after, 

621 
technic of, 611 
Porro operation, 646 
Position of foetus, 84 
Postpartum hemorrhage, 459 
Precipitate labor, 366 
Pregnane}', abdominal distention in, 39 



Pregnancy, albuminuria in, 22 
amenorrhoea in, 28 
ampullar, 2)-Z 
anteversion in, 10 
appendicitis in, 305 
asthma in, 299 
ballottement in, 38 
cancer of the cervix in, 238 
cardiac disease in, 255 
care of nipples in, 59 
changes in, adnexa in, 12 

alimentary tract in, 20 

bladder in, 2^^ 

breasts in, 42 

cervix in, 12 

glandular system in, 21 

heart and circulatory system in, 
18 

mental and nervous sj'stem, 24 

nipples in. 42 

pelvic floor in, 16 

pelvic joints in, 16 

perineum in, 16 

skin in, 2^^ 

urinary tract in, 22 

urine in, 22 

uterus in, i 

vagina in, 16 

vulva in, 16 
chorea in, 281 
coitus in, 58 

course of, in pelvic contraction, 521 
cystitis in, 301 
cystocele in, 2^2 
determination of period of, 45 
diabetes in, 22 
diagnosis of, 2y 
differential diagnosis of, 49 
displacement of kidne3's in, 22, 
duration of, 44 
endometritis in. 223 
enlargement of pelvis in, 17 
exercise in. 57 
extra-uterine. ■},22 
frequent urination in. 23 
gastro-intestinal disturbances, 304 
general changes in, 18 
gonorrhcea in, 227 
herpes in, 307 
icterus gravis in, 280 
impetigo herpetiformis in, 307 
infectious diseases in, 283 

acute, 291 

chronic, 283 

syphilis, 283 
tuberculosis, 290 
intermittent uterine contractions in, 

-^- 
isthmic, 2)-Z 
management of, 54 
metabolism in, 25 
multiparity, diagnosis of, 47 



INDEX 



743 



Pregnancy, multiple, 212 

"nause'a and vomiting in, 29 
nephritis in, 300 
neuralgia in, 306 
neuritis in, 305 
nutrition in, 25 
oedema in, 20 
osteophytes in, 25 
output of urea in, 22 
ovarian, 323 
ovarian cysts in. 236 
patholog}- of, 223 
physiology of, i 
pigmentation in. 23 
prolapse of uterus in, 244 
pruritus, general and local in, 305 
pyelitis and ureteritis in, 302 
quickening in. 38 
respiratory changes, 20 
serodiagnosis of, 48 
spurious, 50 
striae of, 24 

surgical operations in, 307 
symptoms of, 28 
teeth in, 60 
toxaemia of, 253 
transient paralyses in, 306 
tumors in, 229 
urinalysis in, 60 
vaginitis in, 226 
vulvitis in, 226 
Premature labor, 308 

induction of, 570 
Presentation of foetus, 87 

theories concerning, 91 
Prolapse, of pregnant uterus, 244 
of puerperal uterus, 209 
of umbilical cord. 426 
Pruritus in pregnancy, 305 
Pseudocyesis, 50 
Psychoses in pregnancy, 24 
in the puerperium, 729 
Pubiotomy, after-treatment of, 65o 
delivery of foetus after, 659 
Doderlein's method of, 657 
indications for, 661 
in pelvic contraction, 536 
prognosis in, 663 
Puerperal infection, abscess in, 692 

acute sepsis in, 694 

bacteriology of, 686 

diagnosis of, 699 

endocarditis in, 697 

femoral phlebitis in, 698 

frequency of, 683 

pyaemia in, 695 

sapraemia in, 685 

septicaemia in, 686 

thrombosis in, 699 
Puerperium, acetonuria in, 193 
anteflexion in, 183 
bladder in, 190 



Puerperium, blood in, 192 
bowels in, 190 
catheter in, 199 

characteristics of uterus in, 183 
chill in, 189 
clinical course of, 189 
conduct of, 194 

abdominal binder, 196 

after-pains, 197 

attention to bladder and bowels, 
199 

care of breasts, 203 

diet, 198 

douches, 199 

duration of confinement to bed, 
209 

posture in bed, 208 

prevention of infection, 195 

rest and sleep, 194 

temperature record, 201 
descent of fundus in, 189 
embolism in, 209, 697 
n:Lfection during, 683 
intercurrent affections, 728 
involution of cervix and vagina, 
187 

of uterus, 183 
lactation, 193 
lochia, 191 
lochiometra, 727 
nervous system in, 191 
pathology of, 683 
physical shock in, 461 
position of fundus in, 184 
skin in, 190 
urine in, 193 
weight and appetite, 191 
Pulse in the puerperium, 201 
Pyelitis in pregnancy, 302 
in the puerperium, 729 

Quickening in diagnosis of pregnancy. 

38 

Quinine in uterine inertia, 363 

Rectocele In pregnancy, 252 
Repositor for prolapsus funis, 429 
Respiration, artificial, 410 
Retained placenta, 175 
Retraction ring, 365 
Retroflexion, cause of abortion, 241 

due to pelvic contraction, 521 

incarceration of uterus in, 243 

of gravid uterus, 240 

of puerperal uterus, 210 
Retromammary abscess, 718 
Retroversion of gravid uterus, 240 
Rhachitic pelvis, 494 
Rhomboid of Michaelis, 509 
Ring of Bandl, 365 
Robb's legholder, 543 
Roberts pelvis, 504 



744 



INDEX 



Rubber gloves, 145 

Rupture of uterus, etiology of, 448 

frequency of, 446 

in labor, 448 

in pregnancy, 447 

mechanism of, 450 

prognosis of, 452 

treatment of, curative, 454 
prophylactic, 452 

Salt solution in eclampsia, 271 
in hemorrhage, 469 
in puerperal infection, 710 
Saprsemia, 685 
Scarlet fever in pregnancy, 291 

in puerperium, 728 
Scoliotic pelvis, 505 
Scopolamine anaesthesia, 157 
Septicaemia, puerperal, 686 
Septic rash in the puerperium, 728 
Serodiagnosis of pregnancy, 48 
Sex, determination of. 48 
Shock in inversion of uterus, 456 

in the puerperium. 461 
Shoulder presentation, 92 
Shoulders, delivery of, 125 

palpation of, 388 
Signs of pregnancy. 28 
Simpson's forceps, ^jG 
Skin in pregnancy, 22, 

pigmentation of. 24 

striae on, 24 
Souffle, funic, 39 

uterine, 39 
Spirochaeta pallida. 285 
Spondylolisthesis, 505 
Spurious pregnancy. 50 
Striae of pregnancy. 24 

in other conditions, 24 
Subinvolution of uterus, J2^ 

avoidance of curette, 726 
Succenturiate placenta, 342 
Superfecundation, S- 
Superfetation, 52 
Superinvolution of uterus, 726 

relation to lactation, ';2'/ 
Suprasymphyseal Caesarean section, 649 
Superrotation of shoulders, 125 
Suprarenal capsules, hypertrophy of, 21 
Surgical operations in pregnancy, 307 

in syphilis, 289 
Sutures of fetal head, 152 
Symphysiotomy, after-treatment of. 6^6 

delivery after, 655 

indications, 661 

in pelvic contraction, ^2^ 

prognosis in. 663 

technic of, 653 

various methods, 656 
Syphilis, condition of fcetus in. 285 

course in pregnancy, 284 

placenta in, 285 



Syphilis, postconceptional, 284 
treatment of, 289 

Tamponade in induction of abortion, 

in induction of labor, 572 
in placenta praevia, 479 
intra-uterine, 464 
Tarnier basiotribe, 672 
cephalotribe. 671 
forceps, 578 
Temperature in the puerperium. 201 
Tetanus in the puerperium, 726 

of the uterus, 365 
Threatened abortion, 313 
Thrombosis, 298, 699 
Thyroid extract in eclampsia, 21 
in toxemia, 21 
gland in pregnancy, 21 
Tongue traction in asphyxia neona- 
torum, 413 
Toxaemia, diagnosis of, 257 
oxygen in, 260, 406 
preeclamptic, 253 
treatment of, 258 
Transverse contraction of pelvis, 504 
positions, 375 

diagnosis of, 376 
rupture of membranes in, 379 
spontaneous evolution in, 380 
treatment of, 380 
version in, 380 
Tubal abortion, 313, 2>-Z 

pregnancy, 322 
Tuberculosis, pulmonary, in pregnancy, 
290 
chronic, 290 
acute miliary, 295 
Tumors in labor, 229 
in pregnancy, 229 
Tympanites in the puerperium, 192 
Typhoid fever in pregnancj^ 294 
in the puerperium, 729 

Umbilical cord, anomalies of, 344 

abnormal insertion, 344 

knots, 345 

short, 460 

variations in length. 345 

asepsis in handling, 172 

care of, 171 

coiling of, 168 

first dressing of, 172 

ligation of, 171 

passing loop over fetal head. 
168 

prolapse of, 426 
causes, 427 
fetal prognosis, 427 

reposition of prolapsed, 429 

short, as cause of hemorrhage, 
460 



INDEX 



745 



Urea in eclampsia, 255 

in pregnancy, 22 
Ureteritis in pregnancy, 302 
L'reters in pregnancy, 23 

compression of, 22, 
Urinary changes in pregnancy, 22 

in the puerperium. 193 
Urine, examination of. in pregnancy, 60 
in eclampsia, 2}^^, 264 
in toxaemia, 254 
Uterus, innervation of, 109 

pregnant anomalies in forces of, 353 

anteversion of, 10 

cancer of cervix in, 283 

contraction ring, 112 

contractions of, 42, 109 

displacements of, 240 

general changes in. 9 

height of fundus of, 40 

hernia of. 246 

hypertrophy of, 2 

inclination of, 11 

inertia of, 354 

intermittent contractions of, 42 

inversion of, 455 

lower uterine segment of, 9 

lymphatic system of. 7 

mucous membrane of. 8 

muscular arrangement of. 5 

myoma of, 229 

nerves of, 7, 109 

nutrition and development of, 6 

perforation of, 318 

prolapse of, 244 

relations of, 12 

retractile function of, 6, 110,365 

retroflexion of, 240 

retroversion of, 240 

tetanic contraction of, 365 

torsion of, 11 

tumors of, 229 

vascular supply of, 7, 9 
puerperal anteflexion of, 183 

atonic, bimanual compression 
of, 468 _ 

characteristics of, 183 

inversion of, 455 

involution of, 182 

lactation atrophy of, 726 

prolapse of, 209 

retroversion of, 210 

subinvolution of, 725 
structural anomalies of, 246 

bicornis, 247 

didelphys, 246 

duplex. 246 

unicornis, 247 

with rudimentary horn, 250 



Vagina, atresia of, 250 

bacteriology of, 688 

changes of, in labor, 188 
in pregnancy, 16 
in the puerperium, 188 

discoloration of, in pregnancy, 2)7 

double, 247 

h?ematoma of, 444 

inflammation of, in pregnancy, 226 

injuries of, 445 

laceration of, 445 

mucosa of, 16 

secretion of, 16 
Vaginal congestion in pelvic contrac- 
tion, 526 

Csesarean section, 559 
advantages, 564 
disadvantages, 565 

douche, 706 

in subinvolution, 726 

examination in labor, 151 
in pregnancy, 82 

fistula in pelvic contraction, 526 

secretion, 30 

tamponade in placenta prc'evia, 479 

wall, laceration of, 442 
^Varicosities, in pregnancy, 19, 351 
Velamentous insertion of umbilical 

cord, 344 
Ventro fixation, dystocia due to, 243 
Veratrum viride in eclampsia, 270 
Version, bipolar, 609, 62)2, 

cephalic, 635 

external, 630 

in pelvic contraction, 534 

in transverse position, 380 

in vaginal hysterotomy, 563 

podalic, 609 
Vertex presentation, 87 
Vesico-vaginal fistula, 526 
Villi, chorionic, in syphilis, 285 
Vomiting in pregnancy, 273 

toxsemic, 275 
Voorhees bag for cervical dilator, 51^4 

in induction of labor, 572 
Vulva, atresia of, 250 

changes of, in pregnancy, 16 

diphtheria of, 728 

dressing of, 143, 173 

haematoma of, 444 
didelphys, 247 

oedema of, in pelvic contraction, 526 

pruritus of, 305 
Vulvitis in pregnancy, 226 

Walcher's position, 535 

White infarcts of placenta, 342 



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